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General NPI Number Information
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NPI Number | 1225339260
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Entity Type | Individual
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Provider Name | JAKIME LAMAR ELLISON P-LCSW
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Gender | Male
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Dates
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Enumeration Date | 11/08/2010
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Last Update Date | 11/08/2010
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Provider Practice Location Address
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Address Line | 3405 W WENDOVER AVE SUITE A
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City | GREENSBORO
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State | NC
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Zip | 27407-2377
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Country | US
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Telephone | 336-235-2427
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Fax |
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Provider Business Mailing Address
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Address Line | 724 CREEK RIDGE RD LOT# 142
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City | GREENSBORO
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State | NC
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Zip | 27406-4821
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Country | US
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Telephone | 336-253-0547
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | P006095
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License Number State | NC
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