Provider Demographics
NPI:1114493863
Name:ELLISON, JENNY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2094 CHELSEA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:AL
Mailing Address - Zip Code:35051-3380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 ONE NINETEEN BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-7236
Practice Address - Country:US
Practice Address - Phone:800-401-6335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist