Healthcare Provider Details

I. General information

NPI: 1578798625
Provider Name (Legal Business Name): JENNIFER ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 S TABLE MOUNTAIN LOOP
CHEYENNE WY
82009-7423
US

IV. Provider business mailing address

754 S TABLE MOUNTAIN LOOP
CHEYENNE WY
82009-7423
US

V. Phone/Fax

Practice location:
  • Phone: 307-778-8527
  • Fax: 307-638-0467
Mailing address:
  • Phone: 307-778-8527
  • Fax: 307-638-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: