Individual
ELIZABETH DETWEILER JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
42 TOWN ST STE 300, NORWICH, CT 06360-2339
(860) 886-0567
Mailing address
110 COOKTOWN RD, PRESTON, CT 06365-8801
(860) 917-3523
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
132311
CT
363LF0000X
Family Nurse Practitioner
Primary
009070
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
009070
CT LIC
CT
Enumeration date
06/01/2020
Last updated
08/03/2020
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