Active NPI
Elizabeth Gross Jackson
- Registered Dietitian
- Minneapolis, MN
National Provider Identifier
1922302322
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- 2952
- Practice address
- 621 W Lake St Ste 350
Minneapolis, MN 55408-2952 - Phone
- (612) 979-2276
- Fax
- (651) 925-0427
- NPI assigned
- Dec 29, 2010
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 2952 | MN | Primary |
Addresses
Primary practice location
621 W Lake St Ste 350
Minneapolis, MN 55408-2952
Mailing address
621 W Lake St Ste 350
Minneapolis, MN 55408-2952
Phone (612) 979-2276
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20110408000164 | MN | Practitioner - Registered Dietitian Or Nutrition Professional | 3971787334 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2952 | MN | MD | Chiropractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1293580800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1574294400000",
"number": "1922302322",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "621 W LAKE ST STE 350",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554082952",
"telephone_number": "612-979-2276",
"fax_number": "651-925-0427"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "621 W LAKE ST STE 350",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554082952",
"telephone_number": "612-979-2276",
"fax_number": "651-925-0427"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "ELIZABETH",
"middle_name": "GROSS",
"name_prefix": "Ms.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2010-12-29",
"last_updated": "2019-11-21",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "MN",
"license": "2952",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minneapolis, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 21, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.