Healthcare Provider Details

I. General information

NPI: 1760170088
Provider Name (Legal Business Name): MADISON JACOBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

10625 W NORTH AVE STE 101B
WAUWATOSA WI
53226-2315
US

V. Phone/Fax

Practice location:
  • Phone: 414-585-1000
  • Fax:
Mailing address:
  • Phone: 414-877-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number87067-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: