Healthcare Provider Details

I. General information

NPI: 1881505915
Provider Name (Legal Business Name): LAKEESHA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7607 W TOWNSEND ST STE 108
MILWAUKEE WI
53222-3965
US

IV. Provider business mailing address

9715 W LOLITA AVE
MILWAUKEE WI
53224-3350
US

V. Phone/Fax

Practice location:
  • Phone: 414-803-8934
  • Fax: 414-539-1800
Mailing address:
  • Phone: 414-803-8934
  • Fax: 414-539-1800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number19147-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: