Healthcare Provider Details

I. General information

NPI: 1366081127
Provider Name (Legal Business Name): JAMIE LYNN ELLIS MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 MASON HEADLEY RD
LEXINGTON KY
40504-2246
US

IV. Provider business mailing address

2050 VERSAILLES RD
LEXINGTON KY
40504-1405
US

V. Phone/Fax

Practice location:
  • Phone: 859-367-7127
  • Fax:
Mailing address:
  • Phone: 859-367-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number131972
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number131972
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: