Provider Demographics
NPI:1093878449
Name:ELLIOTT, JENNIFER LEE (MED)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 S PERRY ST
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1900
Mailing Address - Country:US
Mailing Address - Phone:303-949-1087
Mailing Address - Fax:303-681-0413
Practice Address - Street 1:823 S PERRY ST
Practice Address - Street 2:ST 100A
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1900
Practice Address - Country:US
Practice Address - Phone:303-949-1087
Practice Address - Fax:303-681-0413
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1519101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional