Provider Demographics
NPI:1841380599
Name:ELLIOTT, JENNIFER LYNN (MPA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1143
Mailing Address - Country:US
Mailing Address - Phone:269-781-6600
Mailing Address - Fax:269-781-9228
Practice Address - Street 1:202 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OLIVET
Practice Address - State:MI
Practice Address - Zip Code:49076-9465
Practice Address - Country:US
Practice Address - Phone:269-781-6600
Practice Address - Fax:269-781-9228
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0979851OtherDEA
A36028009Medicare PIN
MIOA37669Medicare PIN
ME0979851OtherDEA