Provider Demographics
NPI:1700291077
Name:ELLIOTT, JACIE (DPT)
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 BERRYWOOD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:573-449-6563
Practice Address - Street 1:3301 BERRYWOOD DR
Practice Address - Street 2:SUITE 204
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6517
Practice Address - Country:US
Practice Address - Phone:573-449-8771
Practice Address - Fax:573-449-6563
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014026926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist