Provider Demographics
NPI:1700599370
Name:JACKSON, ELIZABETH KAGANDA
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:KAGANDA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:JOAN
Other - Last Name:KAGANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:705 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CTY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2941
Mailing Address - Country:US
Mailing Address - Phone:573-291-5303
Mailing Address - Fax:
Practice Address - Street 1:705 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CTY
Practice Address - State:MO
Practice Address - Zip Code:65101-2941
Practice Address - Country:US
Practice Address - Phone:573-291-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide