Basic Information
| Provider Information | |||||||||
| NPI: | 1780654608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLEGOOD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4841 MONROE ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194710493 | ||||||||
| FaxNumber: | 4194722772 | ||||||||
| Practice Location | |||||||||
| Address1: | 5200 HARROUN RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241952 | ||||||||
| FaxNumber: | 4198241751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50-002331 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50-002331 | 01 | OH | PA LICENSE | OTHER | P00354306 | 01 | OH | RR MEDICARE | OTHER |