Provider Demographics
NPI:1477730059
Name:JACKSON, ELISHA M (LPN)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 POST AVE
Mailing Address - Street 2:APT 16
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2309
Mailing Address - Country:US
Mailing Address - Phone:585-729-8792
Mailing Address - Fax:
Practice Address - Street 1:767 POST AVE
Practice Address - Street 2:APT 16
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-2309
Practice Address - Country:US
Practice Address - Phone:585-729-8792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-26
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY78152301163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse