Provider Demographics
NPI:1811755192
Name:JACKSON, ELIZABETH IRENE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:IRENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 MACK BEAN RD
Mailing Address - Street 2:
Mailing Address - City:RED BOILING SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37150-6015
Mailing Address - Country:US
Mailing Address - Phone:615-699-7315
Mailing Address - Fax:
Practice Address - Street 1:2106 MACK BEAN RD
Practice Address - Street 2:
Practice Address - City:RED BOILING SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37150-6015
Practice Address - Country:US
Practice Address - Phone:615-699-7315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant