=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740687524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER ELLIS, M.ED, LPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2014
-----------------------------------------------------
Last Update Date | 11/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 464 PARKER AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-413-6089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 464 PARKER AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-413-6089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | JENNIFER MARIE ELLIS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 609-413-6089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | PC006176
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------