Provider Demographics
NPI:1245341817
Name:ELLIS-JAMMAL, MARY ANN (MD)
Entity type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:ELLIS-JAMMAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N. SUNRISE AVE SUITE 1403
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-771-4414
Mailing Address - Fax:916-771-4411
Practice Address - Street 1:151 N. SUNRISE AVE SUITE 1403
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-771-4414
Practice Address - Fax:916-771-4411
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37659208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A376590Medicaid
00A376590Medicare ID - Type Unspecified
CA00A376590Medicaid