Provider Demographics
NPI:1235903766
Name:ELLIOTT, JAHZMON SEVILLE
Entity Type:Individual
Prefix:
First Name:JAHZMON
Middle Name:SEVILLE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 BLAKE AVE NW APT 33
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3464
Mailing Address - Country:US
Mailing Address - Phone:234-804-9392
Mailing Address - Fax:
Practice Address - Street 1:2701 BLAKE AVE NW APT 33
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3464
Practice Address - Country:US
Practice Address - Phone:234-804-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN167053.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse