Provider Demographics
NPI:1255845111
Name:JACKSON, ELIZABETH ANNE (FNP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2363
Mailing Address - Country:US
Mailing Address - Phone:812-524-4253
Mailing Address - Fax:812-524-4255
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-524-4253
Practice Address - Fax:812-524-4255
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008703A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily