Healthcare Provider Details

I. General information

NPI: 1366425373
Provider Name (Legal Business Name): JACALYN MARY STEWART ANDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16265 CUMBERLAND TRL
BROOKFIELD WI
53005-2212
US

IV. Provider business mailing address

5726 S 113TH ST
HALES CORNERS WI
53130-1806
US

V. Phone/Fax

Practice location:
  • Phone: 262-790-0079
  • Fax:
Mailing address:
  • Phone: 414-425-8931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: