Provider Demographics
NPI:1649460312
Name:ELLIOTT, JEFFREY BRYAN (MC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BRYAN
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 E BASELINE RD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4676
Mailing Address - Country:US
Mailing Address - Phone:602-550-2073
Mailing Address - Fax:
Practice Address - Street 1:4824 E BASELINE RD
Practice Address - Street 2:SUITE 124
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4676
Practice Address - Country:US
Practice Address - Phone:602-550-2073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10063101Y00000X
AZLISAC-10173101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)