Active NPI
Jenna Ellison, PHD
- Clinical Psychologist
- Raleigh, NC
National Provider Identifier
1609428168
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 5608
- Practice address
- 4030 Wake Forest Rd Ste 349
Raleigh, NC 27609-0010 - Phone
- (919) 438-1626
- NPI assigned
- Jul 15, 2019
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Health Psychologist | 103TH0004X | 5608 | NC | |
| Clinical Psychologist | 103TC0700X | 5608 | NC | Primary |
Addresses
Primary practice location
4030 Wake Forest Rd Ste 349
Raleigh, NC 27609-0010
Mailing address
4030 Wake Forest Rd Ste 349
Raleigh, NC 27609-0010
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)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5608 | NC | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1563148800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1648166400000",
"number": "1609428168",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4030 WAKE FOREST RD STE 349",
"city": "RALEIGH",
"state": "NC",
"postal_code": "276090010"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4030 WAKE FOREST RD STE 349",
"city": "RALEIGH",
"state": "NC",
"postal_code": "276090010",
"telephone_number": "919-438-1626"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLISON",
"first_name": "JENNA",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2019-07-15",
"last_updated": "2022-03-25",
"certification_date": "2020-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "103TH0004X",
"taxonomy_group": "",
"desc": "Psychologist, Health",
"state": "NC",
"license": "5608",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "NC",
"license": "5608",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Raleigh, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.