MEDICARE: ELIZABETH CONNER JACKSON MD

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	2080P0210X	Pediatric Nephrology Physician	35. 082704	OH
2	2080P0210X	Pediatric Nephrology Physician	23556	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790705135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH CONNER JACKSON MD

Provider Business Mailing Address
First Line	:	3333 BURNET AVE
Second Line	:	UROLOGY, CCHMC
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3026
Country	:	US
Telephone Number	:	513-636-4975
Fax Number	:	513-636-1431

Provider Business Practice Location Address
First Line	:	740 S LIMESTONE
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40536-0001
Country	:	US
Telephone Number	:	859-323-5481
Fax Number	:

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/31/2011

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