Healthcare Provider Details

I. General information

NPI: 1871754374
Provider Name (Legal Business Name): JENNIFER DIANE ELLZEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BAPTIST DR STE 301
MADISON MS
39110-2012
US

IV. Provider business mailing address

7731 OLD CANTON RD STE B
MADISON MS
39110-6115
US

V. Phone/Fax

Practice location:
  • Phone: 601-499-0935
  • Fax: 601-499-0936
Mailing address:
  • Phone: 601-499-0935
  • Fax: 601-499-0936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-35203
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32289
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: