Healthcare Provider Details

I. General information

NPI: 1720786031
Provider Name (Legal Business Name): JASON DEAN ELLIS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 E MISSOURI AVE
PHOENIX AZ
85014-2708
US

IV. Provider business mailing address

1102 E MISSOURI AVE
PHOENIX AZ
85014-2708
US

V. Phone/Fax

Practice location:
  • Phone: 602-999-8389
  • Fax: 602-613-4165
Mailing address:
  • Phone: 602-999-8389
  • Fax: 602-613-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberOTC13694
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT15837
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: