Provider Demographics
NPI:1558440081
Name:JACKSON, ELAINE S (RN)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10542 VIOLET DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4718
Mailing Address - Country:US
Mailing Address - Phone:801-572-6064
Mailing Address - Fax:
Practice Address - Street 1:4460 HIGHLAND DR
Practice Address - Street 2:STE. #300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3543
Practice Address - Country:US
Practice Address - Phone:801-273-6366
Practice Address - Fax:801-273-6363
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT335751-3102163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management