Healthcare Provider Details

I. General information

NPI: 1972167161
Provider Name (Legal Business Name): JORDAN MICHAEL ELLIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W PERIMETER RD
JB ANDREWS MD
20762-6602
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG. 4554, 59 MDW/GME, JBSA LACKLAND
JBSA LACKLAND TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 240-857-7186
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007310
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: