Healthcare Provider Details

I. General information

NPI: 1720421795
Provider Name (Legal Business Name): ALBERT JACKSON AODA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W CAPITOL DR
MILWAUKEE WI
53216-2530
US

IV. Provider business mailing address

4950 N 21ST STREET
MILWAUKEE WI
53209-5750
US

V. Phone/Fax

Practice location:
  • Phone: 414-810-6691
  • Fax:
Mailing address:
  • Phone: 414-301-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number16862-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16862-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: