Basic Information
| Provider Information | |||||||||
| NPI: | 1477658094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 DEPT 0420 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014842052 | ||||||||
| FaxNumber: | 9015078298 | ||||||||
| Practice Location | |||||||||
| Address1: | 4441 E LOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880118267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014842052 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 26906 | TN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 4035038 | 01 | TN | BLUE CROSS | OTHER | 3092947 | 05 | TN | MEDICAID |