Provider Demographics
NPI:1386870285
Name:JACKSON, ELIZABETH MICHELE (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MICHELE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3044 HIGHLAND GROVE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4596
Mailing Address - Country:US
Mailing Address - Phone:423-483-0700
Mailing Address - Fax:
Practice Address - Street 1:444 CLINCHFIELD ST
Practice Address - Street 2:SUITE 2900
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3606
Practice Address - Country:US
Practice Address - Phone:423-245-6101
Practice Address - Fax:423-245-2396
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51246208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I026728Medicare PIN