Provider Demographics
NPI:1679788350
Name:ELLINGEN, JAMIE PATRICIA (LPN)
Entity type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:PATRICIA
Last Name:ELLINGEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:JAMIE
Other - Middle Name:PATRICIA
Other - Last Name:KOCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1724 W 3RD AVE APT B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2790
Mailing Address - Country:US
Mailing Address - Phone:614-425-8341
Mailing Address - Fax:
Practice Address - Street 1:5733 CLEARFIELD LN
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-2241
Practice Address - Country:US
Practice Address - Phone:614-798-8843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.127515-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2763684Other7 DIGIT OHIO PROVIDER #