Provider Demographics
NPI:1346506482
Name:JACKSON, ELISHA JANA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISHA
Middle Name:JANA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6991 SWEDE JOHNSEN DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7266
Mailing Address - Country:US
Mailing Address - Phone:816-686-0222
Mailing Address - Fax:
Practice Address - Street 1:6651 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2351
Practice Address - Country:US
Practice Address - Phone:328-826-7735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS2996207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program