Provider Demographics
NPI:1902171390
Name:ELLINGTON, JENNIFER JO (LPN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JO
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3372
Mailing Address - Country:US
Mailing Address - Phone:706-975-3452
Mailing Address - Fax:706-672-3305
Practice Address - Street 1:756 WOODBURY HWY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:GA
Practice Address - Zip Code:30222-1514
Practice Address - Country:US
Practice Address - Phone:706-775-0543
Practice Address - Fax:706-672-3305
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN057366164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse