Healthcare Provider Details

I. General information

NPI: 1750784724
Provider Name (Legal Business Name): ELLA HEPHZIBAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N WEST AVE STE 812
JACKSON MI
49202-2047
US

IV. Provider business mailing address

1905 4TH ST
JACKSON MI
49203-4039
US

V. Phone/Fax

Practice location:
  • Phone: 517-513-3657
  • Fax: 517-513-3693
Mailing address:
  • Phone: 517-513-3657
  • Fax: 517-513-3693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: