Provider Demographics
NPI:1043033129
Name:JACKSON, ELIZABETH RENEE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
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 1:4622 N ROGERS DR
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-1654
Mailing Address - Country:US
Mailing Address - Phone:580-716-1503
Mailing Address - Fax:
Practice Address - Street 1:1301 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4375
Practice Address - Country:US
Practice Address - Phone:405-533-1074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical