Provider Demographics
NPI:1871177162
Name:ELLIOTT, JONATHAN GREGORY (HIS)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:GREGORY
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 NYE ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5150
Mailing Address - Country:US
Mailing Address - Phone:318-366-3207
Mailing Address - Fax:
Practice Address - Street 1:302 BRIDGE ST STE 6
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-2964
Practice Address - Country:US
Practice Address - Phone:318-605-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSHA-696237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist