Healthcare Provider Details

I. General information

NPI: 1174924591
Provider Name (Legal Business Name): JONELLE ENSIGN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 05/28/2022
Certification Date: 05/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 SOLUTIONS WAY STE 110
ROCKLEDGE FL
32955-3623
US

IV. Provider business mailing address

590 SOLUTIONS WAY STE 110
ROCKLEDGE FL
32955-3623
US

V. Phone/Fax

Practice location:
  • Phone: 321-305-4342
  • Fax:
Mailing address:
  • Phone: 321-305-4342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36708
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043131A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1491
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY11427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: