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General NPI Number Information
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NPI Number | 1205291572
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Entity Type | Individual
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Provider Name | GLENDA ELIZABETH JACKSON R.N.
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Gender | Female
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Dates
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Enumeration Date | 12/30/2015
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Last Update Date | 06/25/2025
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Provider Practice Location Address
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Address Line | 12225 71ST ST
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City | KENOSHA
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State | WI
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Zip | 53142-7320
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Country | US
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Telephone | 877-666-7223
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Fax | 262-948-4871
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Provider Business Mailing Address
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Address Line | PO BOX 735044
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City | CHICAGO
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State | IL
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Zip | 60673-5044
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Country | US
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Telephone | 800-326-2250
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Fax |
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 16452
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 16452-33
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License Number State | WI
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