Healthcare Provider Details

I. General information

NPI: 1073135257
Provider Name (Legal Business Name): JANE ELLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7345 COURAGE WAY STE 101
CHATTANOOGA TN
37421-1555
US

IV. Provider business mailing address

7345 COURAGE WAY STE 101
CHATTANOOGA TN
37421-1555
US

V. Phone/Fax

Practice location:
  • Phone: 423-602-9797
  • Fax: 423-602-9796
Mailing address:
  • Phone: 423-602-9797
  • Fax: 423-602-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3145
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: