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General NPI Number Information
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NPI Number | 1922902287
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Entity Type | Individual
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Provider Name | DEMETRIUS EMMANUEL JACKSON
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Gender | Male
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Dates
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Enumeration Date | 10/07/2026
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Last Update Date | 10/07/2026
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Provider Practice Location Address
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Address Line | 138 ALTON DR
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City | MADISON
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State | WI
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Zip | 53718-9156
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Country | US
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Telephone | 757-915-0633
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Fax |
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Provider Business Mailing Address
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Address Line | 701 HIGHLAND AVE
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City | MADISON
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State | WI
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Zip | 53705-2202
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Country | US
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Telephone |
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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 | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number | 1102063-30
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License Number State | WI
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