Individual
MR. JESSE WREN ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
1157 N 300 W, PROVO, UT 84604-6124
(801) 357-7525
Mailing address
1034 N 500 W, PROVO, UT 84604-3380
(801) 357-8108
(801) 373-9941
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
7748699-3501
UT
Other
Enumeration date
10/23/2017
Last updated
10/23/2017
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