Basic Information
| Provider Information | |||||||||
| NPI: | 1316143282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 176 GOODMAN RD W | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386719405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625361020 | ||||||||
| FaxNumber: | 6625361024 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 GOODMAN RD W | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386719405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625361020 | ||||||||
| FaxNumber: | 6625361024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R786799 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.