Provider Demographics
NPI:1003416546
Name:ELLIOTT, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WHITE HALL ST
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:IL
Mailing Address - Zip Code:62078-1011
Mailing Address - Country:US
Mailing Address - Phone:217-691-0364
Mailing Address - Fax:
Practice Address - Street 1:116A N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:IL
Practice Address - Zip Code:62092-1054
Practice Address - Country:US
Practice Address - Phone:217-374-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily