Provider Demographics
NPI:1689008492
Name:JACKSON, ELIZABETH ANNE CAROLINE (PHARM D)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE CAROLINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE-CAROLINE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7712 PARMA LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2016
Mailing Address - Country:US
Mailing Address - Phone:858-729-4735
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist