Provider Demographics
NPI:1104433622
Name:ELLIOTT, JERARD LAMARL
Entity type:Individual
Prefix:
First Name:JERARD
Middle Name:LAMARL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S 1ST ST APT 103
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-3760
Mailing Address - Country:US
Mailing Address - Phone:757-404-1169
Mailing Address - Fax:
Practice Address - Street 1:119 S 1ST ST APT 103
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-3760
Practice Address - Country:US
Practice Address - Phone:757-404-1169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
VA0701010764101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health