Provider Demographics
NPI:1861625196
Name:FEDERICO, JAMIE MARIE ELLISON (MED, EDS, NCC)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:MARIE ELLISON
Last Name:FEDERICO
Suffix:
Gender:F
Credentials:MED, EDS, NCC
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:MARIE
Other - Last Name:ELLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, EDS, NCC
Mailing Address - Street 1:150 SPARTAN DR
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-3468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 SPARTAN DR
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-3468
Practice Address - Country:US
Practice Address - Phone:407-331-8002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health