Provider Demographics
NPI:1114487188
Name:ELLIS, JESSICA MARIE (LCDCIII, CADC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCDCIII, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 AVON CT
Mailing Address - Street 2:
Mailing Address - City:CRESCENT PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1616
Mailing Address - Country:US
Mailing Address - Phone:859-250-8460
Mailing Address - Fax:859-916-6713
Practice Address - Street 1:1450 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3369
Practice Address - Country:US
Practice Address - Phone:859-444-4499
Practice Address - Fax:859-916-6713
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164249101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)