MEDICARE: MRS. JACQUELYN L ELLIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2440-C	NV

General Provider Information

NPI Number	:	1376879155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELYN L ELLIS LCSW

Provider Business Mailing Address
First Line	:	3122 ANCHORMAN WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0558
Country	:	US
Telephone Number	:	702-651-0911
Fax Number	:

Provider Business Practice Location Address
First Line	:	3122 ANCHORMAN WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0558
Country	:	US
Telephone Number	:	702-651-0911
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2009
Last Update Date	:	12/11/2018

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