MEDICARE: JENNIFER L ELLIS P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	05004851A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05004851A	OTHER	IN	PHYSICAL THERAPIST LICENS

General Provider Information

NPI Number	:	1225016934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L ELLIS P.T.

Provider Business Mailing Address
First Line	:	1530 SAINT JOHN CT S
Second Line	:
City	:	BEECH GROVE
State	:	IN
Zip	:	46107-2631
Country	:	US
Telephone Number	:	317-408-2752
Fax Number	:

Provider Business Practice Location Address
First Line	:	7440 N SHADELAND AVE
Second Line	:	SUITE 130
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2029
Country	:	US
Telephone Number	:	317-577-7333
Fax Number	:	317-577-7330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	07/09/2007

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