Provider Demographics
NPI:1548628860
Name:JACKSON, ELAINE MAE
Entity type:Individual
Prefix:MISS
First Name:ELAINE
Middle Name:MAE
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 1:426 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1614
Mailing Address - Country:US
Mailing Address - Phone:218-834-0712
Mailing Address - Fax:218-834-2918
Practice Address - Street 1:426 1ST AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1614
Practice Address - Country:US
Practice Address - Phone:218-343-2308
Practice Address - Fax:218-834-2918
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare