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NPI Code Detail

MEDICARE: JASON DEAN ELLIS LMFT

MEDICARE: JASON DEAN ELLIS LMFT
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
1106H00000XMarriage & Family TherapistLMFT15837AZ
2261QM0855XAdolescent and Children Mental Health Clinic/CenterOTC13694AZ

General Provider Information

NPI Number : 1720786031
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASON DEAN ELLIS LMFT
Provider Business Mailing Address
First Line : 1102 E MISSOURI AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85014-2708
Country : US
Telephone Number : 602-999-8389
Fax Number : 602-613-4165
Provider Business Practice Location Address
First Line : 1102 E MISSOURI AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85014-2708
Country : US
Telephone Number : 602-999-8389
Fax Number : 602-613-4165
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/16/2023
Last Update Date : 05/07/2025

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