Provider Demographics
NPI:1811924012
Name:ELLIS, JAY T (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:JAY T
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1463
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1463
Mailing Address - Country:US
Mailing Address - Phone:208-523-8879
Mailing Address - Fax:208-523-0436
Practice Address - Street 1:3100 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8310
Practice Address - Country:US
Practice Address - Phone:208-523-8879
Practice Address - Fax:208-523-0436
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT231171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID316942OtherBLUE SHIELD
ID804274500Medicaid
IDT0742OtherBLUE CROSS OF IDAHO
ID804274500Medicaid