Healthcare Provider Details

I. General information

NPI: 1639274889
Provider Name (Legal Business Name): ELLISHA MICHELLE JONES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLISHA MICHELLE SMITH LCSW

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE STE 1D03 CDR USA MEDDAC
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6633
  • Fax:
Mailing address:
  • Phone: 912-435-6965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004373
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCSW004373
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerGA LINCESESTATE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: