Provider Demographics
NPI:1932590502
Name:ELLIOTT, JOHNATHAN
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 STEAMBOAT SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-7530
Mailing Address - Country:US
Mailing Address - Phone:361-215-3117
Mailing Address - Fax:
Practice Address - Street 1:4504 STEAMBOAT SPRINGS DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-7530
Practice Address - Country:US
Practice Address - Phone:361-215-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70211101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional