Provider Demographics
NPI:1982682886
Name:JACKOVIC, ELIZABETH A (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:JACKOVIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30170
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-7170
Mailing Address - Country:US
Mailing Address - Phone:302-623-0100
Mailing Address - Fax:
Practice Address - Street 1:200 HYGEIA DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2049
Practice Address - Country:US
Practice Address - Phone:302-623-0100
Practice Address - Fax:302-623-0147
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20003607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEF31743Medicare UPIN
DE017330C90Medicare PIN
DE004042C29Medicare PIN