Healthcare Provider Details

I. General information

NPI: 1821680737
Provider Name (Legal Business Name): JORGONNE MARIE ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9027 SUTPHIN BLVD
JAMAICA NY
11435-3647
US

IV. Provider business mailing address

57 EAST AVE FL 1
VALLEY STREAM NY
11580-3913
US

V. Phone/Fax

Practice location:
  • Phone: 718-526-8400
  • Fax:
Mailing address:
  • Phone: 516-309-9914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: