Provider Demographics
NPI:1902786759
Name:ELLZEY, JACOB JR
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ELLZEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 FORSYTH CT
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:OH
Mailing Address - Zip Code:43021-9701
Mailing Address - Country:US
Mailing Address - Phone:614-327-8337
Mailing Address - Fax:
Practice Address - Street 1:3400 KOHR BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-3051
Practice Address - Country:US
Practice Address - Phone:614-498-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator