Provider Demographics
NPI:1083634026
Name:ELLIS, JONATHAN MATTHEW (BS, DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:ELLIS
Suffix:
Gender:M
Credentials:BS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-1216
Mailing Address - Country:US
Mailing Address - Phone:304-688-1204
Mailing Address - Fax:
Practice Address - Street 1:123 MARKET ST
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-1216
Practice Address - Country:US
Practice Address - Phone:304-688-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV113708911Other4-MOST
WV113708911OtherPEIA
WV113708911OtherMAMSI
WV13708911OtherCIGNA
WV113708911OtherACCORDIA
WV3810001425Medicaid
WV1067067OtherWORKER'S COMP
WV113708911OtherCARELINK
WV11378911OtherSTARMARK
WV001705988OtherBLUE CROSS/ BLUE SHEILD
WV113708911OtherHARRINGTON BENEFITS
WV92064OtherUNICARE
WV4145172Medicare PIN
WV92064OtherUNICARE