Healthcare Provider Details

I. General information

NPI: 1306790464
Provider Name (Legal Business Name): JESSICA ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 VICTORY PKWY
CINCINNATI OH
45206-1735
US

IV. Provider business mailing address

2640 VICTORY PKWY APT 17
CINCINNATI OH
45206-1886
US

V. Phone/Fax

Practice location:
  • Phone: 513-391-2989
  • Fax:
Mailing address:
  • Phone: 513-391-2989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.006869
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: