Provider Demographics
NPI:1699524637
Name:ELLISON, JENNIFER LYNN (LPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ELLISON
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 BALDY MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-9202
Mailing Address - Country:US
Mailing Address - Phone:208-920-5151
Mailing Address - Fax:
Practice Address - Street 1:1033 BALDY MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9202
Practice Address - Country:US
Practice Address - Phone:208-920-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-10373101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional