Healthcare Provider Details

I. General information

NPI: 1740780337
Provider Name (Legal Business Name): JILL MARIE ELLIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3394 E JOLLY RD STE B
LANSING MI
48910-8595
US

IV. Provider business mailing address

1310 GEORGE ST
LANSING MI
48910-1235
US

V. Phone/Fax

Practice location:
  • Phone: 517-975-3520
  • Fax:
Mailing address:
  • Phone: 517-862-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000113
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: