Healthcare Provider Details

I. General information

NPI: 1780495671
Provider Name (Legal Business Name): JOELLE NICOLE ELLSWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2025
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

IV. Provider business mailing address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

V. Phone/Fax

Practice location:
  • Phone: 231-268-0388
  • Fax:
Mailing address:
  • Phone: 231-268-0388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851121795
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: