1043079197 NPI number — DR. JESSICA ROSE ELLEM PHD

Table of content: DR. JESSICA ROSE ELLEM PHD (NPI 1043079197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043079197 NPI number — DR. JESSICA ROSE ELLEM PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLEM
Provider First Name:
JESSICA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WINDER
Provider Other First Name:
JESSICA
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043079197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7341 WILDERNESS PARK DR APT 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48185-5974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-468-8621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 FULLER ROAD
Provider Second Line Business Practice Location Address:
MENTAL HEALTH SERVICE LINE
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-769-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  6351004650 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)