Provider Demographics
NPI:1861525073
Name:ELLISON, JILLIAN L (CCCSLP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:L
Last Name:ELLISON
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 RITTER DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-7577
Mailing Address - Country:US
Mailing Address - Phone:304-582-8098
Mailing Address - Fax:
Practice Address - Street 1:80 MADDEX DR
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-4305
Practice Address - Country:US
Practice Address - Phone:304-876-9422
Practice Address - Fax:304-876-6279
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14001506235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist