Provider Demographics
NPI:1336909035
Name:ELLIS, JATARRA (LPC-A)
Entity type:Individual
Prefix:
First Name:JATARRA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 BANK ST FL 4
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2219
Mailing Address - Country:US
Mailing Address - Phone:203-596-9724
Mailing Address - Fax:
Practice Address - Street 1:255 BANK ST FL 4
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2219
Practice Address - Country:US
Practice Address - Phone:203-596-9724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6792101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health