MEDICARE: MRS. ELIZABETH KAGANDA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide		MO

General Provider Information

NPI Number	:	1700599370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH KAGANDA JACKSON

Provider Business Mailing Address
First Line	:	705 JEFFERSON ST
Second Line	:
City	:	JEFFERSON CTY
State	:	MO
Zip	:	65101-2941
Country	:	US
Telephone Number	:	573-291-5303
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 JEFFERSON ST
Second Line	:
City	:	JEFFERSON CTY
State	:	MO
Zip	:	65101-2941
Country	:	US
Telephone Number	:	573-291-5303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2022
Last Update Date	:	12/28/2022

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