Provider Demographics
NPI:1427718709
Name:ELO, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ELO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HIGH ST APT D
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2910
Mailing Address - Country:US
Mailing Address - Phone:571-469-8692
Mailing Address - Fax:
Practice Address - Street 1:92 MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3366
Practice Address - Country:US
Practice Address - Phone:571-469-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health