Provider Demographics
NPI:1326539602
Name:ELLIS, JENNIFER LYN (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-5810
Mailing Address - Country:US
Mailing Address - Phone:203-330-6000
Mailing Address - Fax:
Practice Address - Street 1:743 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-5810
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-382-1435
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical