Provider Demographics
NPI:1275906364
Name:ELYEA, JENNY MACHELLE (BOCPD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:MACHELLE
Last Name:ELYEA
Suffix:
Gender:F
Credentials:BOCPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105B S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-3709
Mailing Address - Country:US
Mailing Address - Phone:605-274-0138
Mailing Address - Fax:605-274-0139
Practice Address - Street 1:2105B S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-3709
Practice Address - Country:US
Practice Address - Phone:605-274-0138
Practice Address - Fax:605-274-0139
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDC52253224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist