Provider Demographics
NPI:1366583163
Name:ELLIS, JASON MAX (DC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MAX
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WELCH RD
Mailing Address - Street 2:STE 111
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2864
Mailing Address - Country:US
Mailing Address - Phone:248-779-9290
Mailing Address - Fax:
Practice Address - Street 1:4010 PAGE AVE
Practice Address - Street 2:STE 104
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1026
Practice Address - Country:US
Practice Address - Phone:248-489-4044
Practice Address - Fax:248-489-4055
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008416111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU87742Medicare UPIN
MION97540Medicare ID - Type Unspecified
MI95-0-F3-5557-0Medicare UPIN