Provider Demographics
NPI:1467683425
Name:JACKSON, MARY ELIZABETH (RN, LM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:947 CASITAS VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-9738
Mailing Address - Country:US
Mailing Address - Phone:805-649-3063
Mailing Address - Fax:805-649-5418
Practice Address - Street 1:947 CASITAS VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-9738
Practice Address - Country:US
Practice Address - Phone:805-649-3063
Practice Address - Fax:805-649-5418
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN416720163W00000X
CA0024176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse