Provider Demographics
NPI:1619625381
Name:JACKSON, ELIZABETH MARION
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARION
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 CHIPPENHAM LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-6803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9501 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4711
Practice Address - Country:US
Practice Address - Phone:216-368-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program