Healthcare Provider Details

I. General information

NPI: 1013925304
Provider Name (Legal Business Name): JERRY R ELLER MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 NAVINS COURT
MERRITT ISLAND FL
32953
US

IV. Provider business mailing address

945 RICHLAND AVE
MERRITT ISLAND FL
32953
US

V. Phone/Fax

Practice location:
  • Phone: 321-452-3500
  • Fax: 321-452-4343
Mailing address:
  • Phone: 321-452-4659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH2360
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT1334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: