Healthcare Provider Details

I. General information

NPI: 1841007283
Provider Name (Legal Business Name): JENNIFER HICKS ELLERBE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 SWALLOWS WALK
GRAYSON GA
30017-1736
US

IV. Provider business mailing address

1344 SWALLOWS WALK
GRAYSON GA
30017-1736
US

V. Phone/Fax

Practice location:
  • Phone: 770-364-2623
  • Fax:
Mailing address:
  • Phone: 770-364-2623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number199759
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: