1558077883 NPI number — MR. JASON MERRILL ELLIOTT FNP-C

Table of content: MR. JASON MERRILL ELLIOTT FNP-C (NPI 1558077883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558077883 NPI number — MR. JASON MERRILL ELLIOTT FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
JASON
Provider Middle Name:
MERRILL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558077883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13960 STONE JUG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49015-7617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-317-9913
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
363 FREMONT ST STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49017-3391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-324-0799
Provider Business Practice Location Address Fax Number:
269-324-8013
Provider Enumeration Date:
01/30/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  4704292822 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com