Provider Demographics
NPI:1770109175
Name:ELLIOTT, JENNA (MS,BCBA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MS,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HANDLEY RD STE C
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2178
Mailing Address - Country:US
Mailing Address - Phone:678-850-7906
Mailing Address - Fax:
Practice Address - Street 1:190 HANDLEY RD STE C
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2178
Practice Address - Country:US
Practice Address - Phone:678-850-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12041599103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst