Provider Demographics
NPI:1619413861
Name:JACKSON, ELIZABETH MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 OVERDALE DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2586
Mailing Address - Country:US
Mailing Address - Phone:423-715-9858
Mailing Address - Fax:
Practice Address - Street 1:2100 OCOEE APOPKA RD
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-9210
Practice Address - Country:US
Practice Address - Phone:407-889-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22453363L00000X, 363LF0000X
FLAPRN11024679363LF0000X
LA230181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner