Provider Demographics
NPI:1487290524
Name:ELLIS, JEN (LMHC)
Entity type:Individual
Prefix:MRS
First Name:JEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1449
Mailing Address - Country:US
Mailing Address - Phone:978-612-6611
Mailing Address - Fax:
Practice Address - Street 1:727 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01505-1449
Practice Address - Country:US
Practice Address - Phone:978-612-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11383101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health