Provider Demographics
NPI:1699130245
Name:JACKSON, ELIZABETH GRACE (MA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:GRACE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:PHILHAVEN 283 BUTLER ROAD
Mailing Address - City:MT GRETNA
Mailing Address - State:PA
Mailing Address - Zip Code:17064
Mailing Address - Country:US
Mailing Address - Phone:717-273-8871
Mailing Address - Fax:717-675-2990
Practice Address - Street 1:PHILHAVEN 283 BUTLER ROAD
Practice Address - Street 2:
Practice Address - City:MT GRETNA
Practice Address - State:PA
Practice Address - Zip Code:17064
Practice Address - Country:US
Practice Address - Phone:717-273-8871
Practice Address - Fax:717-675-2990
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor