Provider Demographics
NPI:1124562632
Name:JACKSON, ELMIRA
Entity Type:Individual
Prefix:
First Name:ELMIRA
Middle Name:
Last Name:JACKSON
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 1:500 S WARNER AVE APT I4
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32348-5303
Mailing Address - Country:US
Mailing Address - Phone:850-661-0328
Mailing Address - Fax:
Practice Address - Street 1:500 S WARNER AVE APT I4
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348-5303
Practice Address - Country:US
Practice Address - Phone:850-661-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL119839376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide