Provider Demographics
NPI:1285393983
Name:JELLUM, ELLEN (LMT)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:JELLUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929-0141
Mailing Address - Country:US
Mailing Address - Phone:907-874-3361
Mailing Address - Fax:
Practice Address - Street 1:109 LYNCH ST
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929
Practice Address - Country:US
Practice Address - Phone:907-874-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist