Healthcare Provider Details

I. General information

NPI: 1083342315
Provider Name (Legal Business Name): OSTASSIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2022
Last Update Date: 08/14/2022
Certification Date: 08/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11431 N PORT WASHINGTON RD STE 206
MEQUON WI
53092-3462
US

IV. Provider business mailing address

11431 N PORT WASHINGTON RD STE 206
MEQUON WI
53092-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-319-9195
  • Fax:
Mailing address:
  • Phone: 414-319-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: