Provider Demographics
NPI:1528341831
Name:ELLIS, JENNIFER JAN (ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JAN
Other - Last Name:NAUMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:1340 LAKE ROGERS CIR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7217
Mailing Address - Country:US
Mailing Address - Phone:407-897-1363
Mailing Address - Fax:
Practice Address - Street 1:2699 LEE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1753
Practice Address - Country:US
Practice Address - Phone:407-897-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 10492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer