Provider Demographics
NPI:1477959914
Name:JACKSON, ELIZABETH A (NP-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 POPLAR RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1618
Mailing Address - Country:US
Mailing Address - Phone:404-367-3014
Mailing Address - Fax:404-367-3558
Practice Address - Street 1:745 POPLAR RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1618
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:404-367-3558
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146361163W00000X, 363LA2200X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology