NPIMap

Individual provider Active NPI

Jeremy Ellis, CDCA

  • Addiction (Substance Use Disorder) Counselor
  • South Point, OH
National Provider Identifier
1306359393
Registry record updated Apr 5, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X
License
CDCA.164482 Issued in OH
Practice address
48 Private Drive 339
South Point, OH 45680-8919
Phone
(740) 451-1455
NPI assigned
Nov 13, 2017
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) Counselor 101YA0400X CDCA.164482 OH Primary
Case Manager/Care Coordinator 171M00000X

Addresses

Primary practice location

48 Private Drive 339
South Point, OH 45680-8919

Mailing address

48 Private Drive 339
South Point, OH 45680-8919
Phone (740) 451-1455

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
CDCA.164482OHMDAddiction (Substance Use Disorder) Counselor

Practice roles

OrganizationSpecialtyStatusNew patients
Bethesda Services LLC Addiction (Substance Use Disorder) Past Accepting new patients

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1510531200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1522886400000",
    "number": "1306359393",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "48 PRIVATE DRIVE 339",
            "city": "SOUTH POINT",
            "state": "OH",
            "postal_code": "456808919",
            "telephone_number": "740-451-1455"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "48 PRIVATE DRIVE 339",
            "city": "SOUTH POINT",
            "state": "OH",
            "postal_code": "456808919",
            "telephone_number": "740-451-1455"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "JEREMY",
        "credential": "CDCA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-11-13",
        "last_updated": "2018-04-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "OH",
            "license": "CDCA.164482",
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in South Point, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.