Provider Demographics
NPI:1629065701
Name:ELLIOTT, JACOB J (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 MONROE ST
Mailing Address - Street 2:STE 201
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2731
Mailing Address - Country:US
Mailing Address - Phone:419-885-1910
Mailing Address - Fax:419-885-5060
Practice Address - Street 1:5600 MONROE ST
Practice Address - Street 2:STE 201
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2731
Practice Address - Country:US
Practice Address - Phone:419-885-1910
Practice Address - Fax:419-885-5060
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH260103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHELCP18051Medicare ID - Type Unspecified