Healthcare Provider Details

I. General information

NPI: 1710694096
Provider Name (Legal Business Name): MANDY ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 MCCARTY LN
JACKSON OH
45640-7020
US

IV. Provider business mailing address

219 COLUMBIA ST
JACKSON OH
45640-1771
US

V. Phone/Fax

Practice location:
  • Phone: 740-577-9003
  • Fax:
Mailing address:
  • Phone: 740-577-9003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: