Healthcare Provider Details

I. General information

NPI: 1902204431
Provider Name (Legal Business Name): JAN ELLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3738 HARRISON AVE
BUTTE MT
59701-6823
US

IV. Provider business mailing address

90 TIGER ST
SAINT REGIS MT
59866-9757
US

V. Phone/Fax

Practice location:
  • Phone: 406-497-7894
  • Fax: 406-497-7918
Mailing address:
  • Phone: 406-649-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9760
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: