Provider Demographics
NPI:1871900621
Name:ELLINGSWORTH, JESSICA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:ELLINGSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1230
Mailing Address - Country:US
Mailing Address - Phone:920-784-9727
Mailing Address - Fax:866-719-3024
Practice Address - Street 1:4001 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2530
Practice Address - Country:US
Practice Address - Phone:414-810-6691
Practice Address - Fax:866-719-3024
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2126-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional