Provider Demographics
NPI:1831602093
Name:ELLIS, JASON LEE (OTRL)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 ELYSIAN FIELDS AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70117-8511
Mailing Address - Country:US
Mailing Address - Phone:504-620-2209
Mailing Address - Fax:504-620-2846
Practice Address - Street 1:719 ELYSIAN FIELDS AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70117-8511
Practice Address - Country:US
Practice Address - Phone:504-620-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA306766225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist