MEDICARE: MS. LILLIE JACKSON

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1841951621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LILLIE JACKSON

Provider Business Mailing Address
First Line	:	8549 N SERVITE DR UNIT 205
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-2546
Country	:	US
Telephone Number	:	414-807-3824
Fax Number	:

Provider Business Practice Location Address
First Line	:	8549 N SERVITE DR UNIT 205
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-2546
Country	:	US
Telephone Number	:	414-807-3824
Fax Number	:

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

Provider Enumeration Date	:	01/04/2022
Last Update Date	:	01/04/2022

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