Provider Demographics
NPI:1679656847
Name:ELLIOTT, JEFFERY D (NP)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:D
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:SUITE110/160
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-542-6729
Practice Address - Fax:805-269-1597
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12502363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12502OtherNP FURNISHING
AK866OtherADVANCED NP
CA57311OtherPUBLIC HEALTH NURSE
OKR0052489OtherREGISTERED NURSE
CA12502OtherNURSE PRACTITIONER
CA20005000564-34OtherANCC APRN- BC (PSYCH)
AK24836OtherREGISTERED NURSE
CA384948OtherREGISTERED NURSE
AK24836OtherREGISTERED NURSE
CA384948OtherREGISTERED NURSE
CAME0854489OtherDEA (SCHEDULE 2-5)
CA12502OtherNURSE PRACTITIONER
AK24836OtherREGISTERED NURSE