Provider Demographics
NPI:1013925304
Name:ELLER, JERRY R (MS)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:R
Last Name:ELLER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 RICHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953
Mailing Address - Country:US
Mailing Address - Phone:321-452-4659
Mailing Address - Fax:
Practice Address - Street 1:42 NAVINS COURT
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-452-3500
Practice Address - Fax:321-452-4343
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2360101Y00000X
FLMT1334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist