Healthcare Provider Details

I. General information

NPI: 1598146078
Provider Name (Legal Business Name): JAYA NELSON-ELLINGTON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 NISSAN DR
SMYRNA TN
37167-4447
US

IV. Provider business mailing address

1200 NETWORK CENTRE DR
EFFINGHAM IL
62401-4602
US

V. Phone/Fax

Practice location:
  • Phone: 629-283-1531
  • Fax:
Mailing address:
  • Phone: 217-540-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12012279A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019030166
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13256
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: