Provider Demographics
NPI:1497065627
Name:JACKSON, ELIZABETH ANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1830 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4275
Mailing Address - Country:US
Mailing Address - Phone:970-945-8503
Mailing Address - Fax:970-945-0253
Practice Address - Street 1:1830 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4275
Practice Address - Country:US
Practice Address - Phone:970-945-8503
Practice Address - Fax:970-945-0253
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4064363A00000X
GA5995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO394647YPU6Medicare PIN
CO394647YMEWMedicare PIN