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General NPI Number Information
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NPI Number | 1205502317
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Entity Type | Individual
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Provider Name | JOELLE KAELYNN ELLIS LMT
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Gender | Female
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Dates
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Enumeration Date | 08/18/2021
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Last Update Date | 08/18/2021
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Provider Practice Location Address
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Address Line | 5035 NE ELAM YOUNG PKWY STE 500
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City | HILLSBORO
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State | OR
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Zip | 97124-6473
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Country | US
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Telephone | 503-844-4325
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Fax |
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Provider Business Mailing Address
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Address Line | 10926 SW CELESTE LN APT 406
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City | PORTLAND
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State | OR
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Zip | 97225-7111
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Country | US
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Telephone | 541-654-6984
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 21225
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License Number State | OR
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