Healthcare Provider Details

I. General information

NPI: 1831497353
Provider Name (Legal Business Name): JESSICA ANN ELLIS C.N.M
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E BROADWAY ST STE 204
HELENA MT
59601-8049
US

IV. Provider business mailing address

227 RIVERSTONE DR
CANTON GA
30114-5256
US

V. Phone/Fax

Practice location:
  • Phone: 406-457-4366
  • Fax: 406-457-4367
Mailing address:
  • Phone: 770-720-7733
  • Fax: 678-493-9875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: