Provider Demographics
NPI:1659696003
Name:JACKSON, ELIZABETH JEAN (ACNS BC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ACNS BC
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:JEAN
Other - Last Name:AMBELANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNS BC
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-2707
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:254-724-7603
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX644855364SA2200X
TXAP112604364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health