Healthcare Provider Details

I. General information

NPI: 1568746642
Provider Name (Legal Business Name): JENNIFER LEANNE ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W 33RD ST
EDMOND OK
73013-3863
US

IV. Provider business mailing address

1713 NW 148TH ST
EDMOND OK
73013-1396
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-5608
  • Fax: 405-216-5272
Mailing address:
  • Phone: 405-657-6885
  • Fax: 405-216-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: