Basic Information
| Provider Information | |||||||||
| NPI: | 1699130245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | PHILHAVEN 283 BUTLER ROAD | ||||||||
| City: | MT GRETNA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172738871 | ||||||||
| FaxNumber: | 7176752990 | ||||||||
| Practice Location | |||||||||
| Address1: | PHILHAVEN 283 BUTLER ROAD | ||||||||
| Address2: | |||||||||
| City: | MT GRETNA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172738871 | ||||||||
| FaxNumber: | 7176752990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2015 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.