Provider Demographics
NPI:1316784754
Name:ELLEBY, JADA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:ELLEBY
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 1:512 MOSS STREAM LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8845
Mailing Address - Country:US
Mailing Address - Phone:980-395-1132
Mailing Address - Fax:
Practice Address - Street 1:1364 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124-7402
Practice Address - Country:US
Practice Address - Phone:980-292-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30002059235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist