Healthcare Provider Details

I. General information

NPI: 1134435035
Provider Name (Legal Business Name): JACKLYN JUSTUS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax: 414-382-5293
Mailing address:
  • Phone: 414-384-2000
  • Fax: 414-382-5293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number11111-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: