MEDICARE: NICOLE L. JACKSON CSAC, ICS, LPC-IT

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	101Y00000X	Counselor	15477-135
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	15137-132	WI
3	101YM0800X	Mental Health Counselor	638-226	WI
4	101YP2500X	Professional Counselor	7520-125	WI

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	:	1144489261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE L. JACKSON CSAC, ICS, LPC-IT

Provider Business Mailing Address
First Line	:	6815 W CAPITOL DR STE 304
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2056
Country	:	US
Telephone Number	:	414-604-6488
Fax Number	:

Provider Business Practice Location Address
First Line	:	6815 W CAPITOL DR STE 304
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2056
Country	:	US
Telephone Number	:	414-604-6488
Fax Number	:

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

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	08/29/2025

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