Provider Demographics
NPI:1194095406
Name:ELLIS, JENNA LEE (MA, LMHC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:LEE
Other - Last Name:CLAES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 RHODE ISLAND RD STE D
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1370
Mailing Address - Country:US
Mailing Address - Phone:774-955-0494
Mailing Address - Fax:774-250-3210
Practice Address - Street 1:109 RHODE ISLAND RD STE D
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1370
Practice Address - Country:US
Practice Address - Phone:774-955-0494
Practice Address - Fax:774-250-3210
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9907101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health