Provider Demographics
NPI:1518583756
Name:ELLIOTT, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:11138 E DEL AMO BLVD
Mailing Address - Street 2:262
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715
Mailing Address - Country:US
Mailing Address - Phone:562-387-3685
Mailing Address - Fax:
Practice Address - Street 1:18624 DEL RIO PL UNIT D
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9109
Practice Address - Country:US
Practice Address - Phone:562-387-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2357859332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies