MEDICARE: JANA LEIGH ELLIS IX

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	183500000X	Pharmacist	0202216556	VA
2	183500000X	Pharmacist	PD10867	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0202216556	OTHER	VA	PHARMACIST LICENSE
2	PD10867	OTHER	AR	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1487399895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANA LEIGH ELLIS IX

Provider Business Mailing Address
First Line	:	13005 CHIPSTEAD RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-4664
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5210 OAKLAWN BLVD
Second Line	:
City	:	NORTH PRINCE GEORGE
State	:	VA
Zip	:	23860-7336
Country	:	US
Telephone Number	:	804-458-8688
Fax Number	:

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

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	04/29/2022

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Directions to “ JANA LEIGH ELLIS IX ” Practice Location

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