Basic Information
| Provider Information | |||||||||
| NPI: | 1922302322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | GROSS | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 W LAKE ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554082952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129792276 | ||||||||
| FaxNumber: | 6519250427 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 W LAKE ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554082952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129792276 | ||||||||
| FaxNumber: | 6519250427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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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 | 133V00000X | 2952 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.