Basic Information
| Provider Information | |||||||||
| NPI: | 1679656847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618028 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 BISHOP ST | ||||||||
| Address2: | SUITE110/160 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055426729 | ||||||||
| FaxNumber: | 8052691597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 12502 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 12502 | 01 | CA | NP FURNISHING | OTHER | 866 | 01 | AK | ADVANCED NP | OTHER | ME 1624089 | 01 | CA | TELECARE, DEA (SCHEDULE 2-5) | OTHER | 57311 | 01 | CA | PUBLIC HEALTH NURSE | OTHER | R0052489 | 01 | OK | REGISTERED NURSE | OTHER | 12502 | 01 | CA | NURSE PRACTITIONER | OTHER | ME0854489 | 01 | CA | DEA (SCHEDULE 2-5) | OTHER | 20005000564-34 | 01 | CA | ANCC APRN- BC (PSYCH) | OTHER | 24836 | 01 | AK | REGISTERED NURSE | OTHER | 384948 | 01 | CA | REGISTERED NURSE | OTHER |