Healthcare Provider Details

I. General information

NPI: 1336077205
Provider Name (Legal Business Name): JARED MICHAEL ELLIS LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10660 PARK RD STE 3400
CHARLOTTE NC
28210-8461
US

IV. Provider business mailing address

716 CODY CT
FORT MILL SC
29715-7092
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-3840
  • Fax:
Mailing address:
  • Phone: 234-281-4781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number57164
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: