Provider Demographics
NPI:1467024372
Name:ELLIOTT, JAKE ALAN
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:ALAN
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 1:8350 CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-3593
Mailing Address - Country:US
Mailing Address - Phone:317-578-0410
Mailing Address - Fax:317-436-7409
Practice Address - Street 1:8350 CRAIG ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3593
Practice Address - Country:US
Practice Address - Phone:317-578-0410
Practice Address - Fax:317-436-7409
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician