Provider Demographics
NPI:1841532942
Name:ELLISON, JO M (PHD)
Entity type:Individual
Prefix:DR
First Name:JO
Middle Name:M
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 OAK RIDGE WAY E STE 6
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8417
Mailing Address - Country:US
Mailing Address - Phone:701-347-1318
Mailing Address - Fax:701-707-3917
Practice Address - Street 1:530 OAK RIDGE WAY E STE 6
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8417
Practice Address - Country:US
Practice Address - Phone:701-347-1318
Practice Address - Fax:701-707-3917
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5980103T00000X
ND494103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist