Healthcare Provider Details

I. General information

NPI: 1730236258
Provider Name (Legal Business Name): LINDA PAGE ELLIS MA, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3027 SAN DIEGO RD
JACKSONVILLE FL
32207-3691
US

IV. Provider business mailing address

2218 OFF SHORE DR
FERNANDINA BEACH FL
32034-4515
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-7762
  • Fax: 904-348-2818
Mailing address:
  • Phone: 904-491-3398
  • Fax: 904-348-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: