Provider Demographics
NPI:1639383052
Name:ELLIOTT, JERRY LEE (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BANCROFT AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5147
Mailing Address - Country:US
Mailing Address - Phone:510-357-9331
Mailing Address - Fax:510-351-6054
Practice Address - Street 1:1300 BANCROFT AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5147
Practice Address - Country:US
Practice Address - Phone:510-357-9331
Practice Address - Fax:510-351-6054
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT05668Medicare UPIN
CADC015191Medicare ID - Type Unspecified