Provider Demographics
NPI:1841540754
Name:ELLINGTON, JACKIE DWAYNE (EMT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:DWAYNE
Last Name:ELLINGTON
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1725
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-0033
Mailing Address - Country:US
Mailing Address - Phone:706-273-7477
Mailing Address - Fax:706-276-8474
Practice Address - Street 1:1548 OLD HWY 5 SOUTH
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540
Practice Address - Country:US
Practice Address - Phone:706-273-7477
Practice Address - Fax:706-276-8474
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28696146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate