Provider Demographics
NPI:1487399895
Name:ELLIS, JANA LEIGH IX
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:LEIGH
Last Name:ELLIS
Suffix:IX
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13005 CHIPSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-4664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5210 OAKLAWN BLVD
Practice Address - Street 2:
Practice Address - City:NORTH PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23860-7336
Practice Address - Country:US
Practice Address - Phone:804-458-8688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202216556183500000X
ARPD10867183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202216556OtherPHARMACIST LICENSE
ARPD10867OtherPHARMACIST LICENSE