Individual
JESSICA LAINE ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1435 G ST, SPRINGFIELD, OR 97477-4113
(541) 242-4812
(541) 242-4813
Mailing address
PO BOX 1648, EUGENE, OR 97440-1648
(541) 242-4812
(541) 284-2038
Taxonomy
Speciality
Code
Description
License number
State
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
MD172850
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500694329
—
OR
Enumeration date
06/07/2006
Last updated
12/04/2015
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