Provider Demographics
NPI:1063673663
Name:JACOX, ELIZABETH A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:JACOX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1809
Mailing Address - Country:US
Mailing Address - Phone:651-265-3459
Mailing Address - Fax:651-227-9813
Practice Address - Street 1:355 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1809
Practice Address - Country:US
Practice Address - Phone:651-265-3459
Practice Address - Fax:651-227-9813
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 161746-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily