Provider Demographics
NPI:1871754374
Name:ELLZEY, JENNIFER DIANE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:ELLZEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7731 OLD CANTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6115
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:401 BAPTIST DR STE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2012
Practice Address - Country:US
Practice Address - Phone:601-499-0935
Practice Address - Fax:601-499-0936
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-35203208000000X
MS32289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics