Healthcare Provider Details

I. General information

NPI: 1023955267
Provider Name (Legal Business Name): JONTA ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JON ELLIOTT

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S CHURCH ST STE 140I
ROCKY MOUNT NC
27804-5755
US

IV. Provider business mailing address

524 LAKELAND ST
DURHAM NC
27701-4508
US

V. Phone/Fax

Practice location:
  • Phone: 252-765-4186
  • Fax: 252-370-1575
Mailing address:
  • Phone: 843-439-2472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number346094
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: