Provider Demographics
NPI:1699777672
Name:ELLIS, JACQUELINE MARION (PT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARION
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 SOUTHSIDE AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4160
Mailing Address - Country:US
Mailing Address - Phone:828-254-3525
Mailing Address - Fax:828-254-0792
Practice Address - Street 1:90 SOUTHSIDE AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4160
Practice Address - Country:US
Practice Address - Phone:828-254-3525
Practice Address - Fax:828-254-0792
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC078PWOtherBCBS
NC2503979Medicare ID - Type Unspecified