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General NPI Number Information
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NPI Number | 1013000561
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Entity Type | Individual
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Provider Name | DENIS IAN JACKSON PH.D.
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Gender | Male
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 11/12/2008
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Provider Practice Location Address
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Address Line | 11931 W BLUEMOUND RD
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City | WAUWATOSA
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State | WI
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Zip | 53226-3905
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Country | US
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Telephone | 414-276-8669
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Fax | 414-276-1266
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Provider Business Mailing Address
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Address Line | 11931 W BLUEMOUND RD
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City | WAUWATOSA
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State | WI
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Zip | 53226-3905
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Country | US
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Telephone | 414-276-8669
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Fax | 414-276-1266
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1965
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License Number State | WI
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