Healthcare Provider Details

I. General information

NPI: 1598833410
Provider Name (Legal Business Name): EDGAR BASIL JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W MITCHELL ST 223
MILWAUKEE WI
53204-3383
US

IV. Provider business mailing address

1225 W MITCHELL ST 223
MILWAUKEE WI
53204-3383
US

V. Phone/Fax

Practice location:
  • Phone: 414-383-4455
  • Fax: 414-727-8730
Mailing address:
  • Phone: 414-383-4455
  • Fax: 414-727-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberAJ8930984 XJ8930984
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13939-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: