Healthcare Provider Details

I. General information

NPI: 1952544488
Provider Name (Legal Business Name): JAMIE ELLINGWOOD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W DEVON AVE
CHICAGO IL
60660-1302
US

IV. Provider business mailing address

1300 W DEVON AVE
CHICAGO IL
60660-1302
US

V. Phone/Fax

Practice location:
  • Phone: 773-751-7850
  • Fax: 773-338-4049
Mailing address:
  • Phone: 773-751-7850
  • Fax: 773-338-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004875
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: