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General NPI Number Information
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NPI Number | 1720786031
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Entity Type | Individual
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Provider Name | JASON DEAN ELLIS LMFT
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Gender | Male
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Dates
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Enumeration Date | 02/16/2023
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 1102 E MISSOURI AVE
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City | PHOENIX
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State | AZ
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Zip | 85014-2708
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Country | US
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Telephone | 602-999-8389
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Fax | 602-613-4165
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Provider Business Mailing Address
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Address Line | 1102 E MISSOURI AVE
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City | PHOENIX
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State | AZ
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Zip | 85014-2708
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Country | US
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Telephone | 602-999-8389
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Fax | 602-613-4165
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | LMFT15837
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | OTC13694
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License Number State | AZ
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