Provider Demographics
NPI:1598562787
Name:ELLIOTT, JESSICA CHRISTINA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHRISTINA
Last Name:ELLIOTT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2464
Mailing Address - Country:US
Mailing Address - Phone:805-550-6855
Mailing Address - Fax:
Practice Address - Street 1:410 MELVIN ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2464
Practice Address - Country:US
Practice Address - Phone:805-550-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach