Healthcare Provider Details

I. General information

NPI: 1114487188
Provider Name (Legal Business Name): JESSICA MARIE ELLIS LCDCIII, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MADISON AVE
COVINGTON KY
41011-3369
US

IV. Provider business mailing address

419 AVON CT
CRESCENT PARK KY
41017-1616
US

V. Phone/Fax

Practice location:
  • Phone: 859-444-4499
  • Fax: 859-916-6713
Mailing address:
  • Phone: 859-250-8460
  • Fax: 859-916-6713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number164249
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: