Healthcare Provider Details

I. General information

NPI: 1104329556
Provider Name (Legal Business Name): ELIZABETH LUKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E WOODROW WILSON AVE
JACKSON MS
39216-5112
US

IV. Provider business mailing address

1350 E WOODROW WILSON AVE
JACKSON MS
39216-5112
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-2611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number901659
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: