Provider Demographics
NPI:1841462660
Name:ELLESON, JAN ROCHELLE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:ROCHELLE
Last Name:ELLESON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 SPOTTED OAK WOODS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-1437
Mailing Address - Country:US
Mailing Address - Phone:210-493-2470
Mailing Address - Fax:
Practice Address - Street 1:6655 FIRST PARK TEN BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-4308
Practice Address - Country:US
Practice Address - Phone:210-737-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13669235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist