Healthcare Provider Details

I. General information

NPI: 1790705135
Provider Name (Legal Business Name): ELIZABETH CONNER JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

3333 BURNET AVE UROLOGY, CCHMC
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5481
  • Fax:
Mailing address:
  • Phone: 513-636-4975
  • Fax: 513-636-1431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number35. 082704
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number23556
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: