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General NPI Number Information
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NPI Number | 1154869410
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Entity Type | Organization
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Legal Business Name | JACKSONSCOTT2
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Dates
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Enumeration Date | 02/07/2017
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Last Update Date | 02/07/2017
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Provider Practice Location Address
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Address Line | 4573 N. 22ND STREET
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City | MILWAUKEE
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State | WI
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Zip | 53209
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Country | US
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Telephone | 414-517-2825
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Fax |
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Provider Business Mailing Address
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Address Line | 4573 N 22ND ST
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City | MILWAUKEE
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State | WI
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Zip | 53209-6309
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Country | US
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Telephone | 414-517-2825
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Fax |
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Authorized Official
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Title or Position | LPN
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Name | LATASHA JACKSON
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Credential | LPN
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Telephone | 414-517-2825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3140N1450X
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Taxonomy Name | Pediatric Skilled Nursing Facility
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License Number | 317445-31
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License Number State | WI
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