Healthcare Provider Details

I. General information

NPI: 1265866370
Provider Name (Legal Business Name): JOURDAN M ELLIS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 MAIN AVE
TILLAMOOK OR
97141-3816
US

IV. Provider business mailing address

906 MAIN AVE
TILLAMOOK OR
97141-3816
US

V. Phone/Fax

Practice location:
  • Phone: 503-842-8201
  • Fax: 503-815-1870
Mailing address:
  • Phone: 503-842-8201
  • Fax: 503-815-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: