| Doctor Name: | MR. JEROME L ELLIS |
| NPI Number: | 1023008638 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | C004119 |
| Business Practice Address: | 1050 Jabarrah Ave Seymour Johnson Afb Goldsboro, NC - 275312310 |
| Business Phone Number: | 9197220928 |
| Business Fax Number: | 9197221952 |
| Mailing Address: | 1050 Jabarrah Ave, Seymour Johnson Afb GOLDSBORO |
| State: | NC |
| Postal Code: | 275312310 |
| Phone Number: | 9197220928 |
| Fax Number: | 9197221952 |
| NPI Enumeration Date: | 10/25/2005 |
| NPI Last Update Date: | 01/22/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | C004119 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |