Healthcare Provider Details

I. General information

NPI: 1881058675
Provider Name (Legal Business Name): PETER C. JACKSON, PSYD CONSULTING, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAY O VAC DR SUITE 220
MADISON WI
53711-2479
US

IV. Provider business mailing address

700 RAYOVAC DRIVE SUITE 220
MADISON WI
53711-2476
US

V. Phone/Fax

Practice location:
  • Phone: 608-276-9191
  • Fax: 608-276-9144
Mailing address:
  • Phone: 608-276-9191
  • Fax: 608-276-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number180557
License Number StateWI

VIII. Authorized Official

Name: PETER JACKSON
Title or Position: PRESIDENT
Credential:
Phone: 608-318-3050