Provider Demographics
NPI:1457130247
Name:ELLIOTT, JORDAN ELYSE (DNP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELYSE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3618
Mailing Address - Country:US
Mailing Address - Phone:224-639-0324
Mailing Address - Fax:
Practice Address - Street 1:1520 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3106
Practice Address - Country:US
Practice Address - Phone:224-639-0324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027471363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty