Healthcare Provider Details

I. General information

NPI: 1811399207
Provider Name (Legal Business Name): JENNIFER ELLEDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 E MURRAY HOLLADAY RD
SALT LAKE CITY UT
84117-5185
US

IV. Provider business mailing address

2616 WEMBLEYCROSS WAY
ORLANDO FL
32828-7963
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-6036
  • Fax: 316-462-0994
Mailing address:
  • Phone: 407-575-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMT 2138
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: