Provider Demographics
NPI:1902420466
Name:JACKSON, ELIZABETH DETWEILER (APRN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DETWEILER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COOKTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06365-8801
Mailing Address - Country:US
Mailing Address - Phone:860-917-3523
Mailing Address - Fax:
Practice Address - Street 1:42 TOWN ST STE 300
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2339
Practice Address - Country:US
Practice Address - Phone:860-886-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT132311163W00000X
CT009070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009070OtherCT LIC