Provider Demographics
NPI:1578676599
Name:JACKSON, ELIZABETH IRENE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:IRENE
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 1:420 N JAMES RD
Mailing Address - Street 2:CHALMERS P. WYLIE VA AMBULATORY CARE CENTER
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-1834
Mailing Address - Country:US
Mailing Address - Phone:614-257-5329
Mailing Address - Fax:614-257-5418
Practice Address - Street 1:420 N JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-1834
Practice Address - Country:US
Practice Address - Phone:614-257-5329
Practice Address - Fax:614-257-5418
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0400852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry