Basic Information
| Provider Information | |||||||||
| NPI: | 1023371333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JABON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 S SPRING AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142578222 | ||||||||
| FaxNumber: | 3145778019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142578222 | ||||||||
| FaxNumber: | 9157422653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2012 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2020016505 | MO | Y | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.