Healthcare Provider Details

I. General information

NPI: 1093043135
Provider Name (Legal Business Name): JESSICA LYNN ELLERMAN L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-8642
  • Fax: 858-452-2246
Mailing address:
  • Phone: 305-243-8642
  • Fax: 858-452-2246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number11486
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP3197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: