Provider Demographics
NPI:1720786031
Name:ELLIS, JASON DEAN (LMFT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 E MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2708
Mailing Address - Country:US
Mailing Address - Phone:602-999-8389
Mailing Address - Fax:602-613-4165
Practice Address - Street 1:1102 E MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2708
Practice Address - Country:US
Practice Address - Phone:602-999-8389
Practice Address - Fax:602-613-4165
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT15837106H00000X
AZOTC13694261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist