Provider Demographics
NPI:1063537744
Name:ELLEN, JENNIE (MD)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:ELLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 S 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-792-1450
Mailing Address - Fax:
Practice Address - Street 1:4600 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1697
Practice Address - Country:US
Practice Address - Phone:520-889-9574
Practice Address - Fax:520-889-5072
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28560208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120952Medicare PIN
AZZ128165Medicare UPIN
AZZ128164Medicare UPIN
AZZ126048Medicare PIN