Provider Demographics
NPI:1982273579
Name:JELLISON, ALEASHA LORAE' (CERTIFIED TECHNITION)
Entity Type:Individual
Prefix:
First Name:ALEASHA
Middle Name:LORAE'
Last Name:JELLISON
Suffix:
Gender:F
Credentials:CERTIFIED TECHNITION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W. HIGHAM ST.
Mailing Address - Street 2:UPSTIARS APARTMENT
Mailing Address - City:ST. JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879
Mailing Address - Country:US
Mailing Address - Phone:989-307-1203
Mailing Address - Fax:
Practice Address - Street 1:111 W. HIGHAM ST.
Practice Address - Street 2:UPSTIARS APARTMENT
Practice Address - City:ST. JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879
Practice Address - Country:US
Practice Address - Phone:989-307-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303025625183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty