MEDICARE: MS. KAREN LYNETTE JACKSON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	29404-031	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39877300	OTHER		EDS

General Provider Information

NPI Number	:	1013111228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAREN LYNETTE JACKSON LPN

Provider Business Mailing Address
First Line	:	2915 N 44TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1710
Country	:	US
Telephone Number	:	414-449-5105
Fax Number	:

Provider Business Practice Location Address
First Line	:	2915 N 44TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1710
Country	:	US
Telephone Number	:	414-449-5105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	07/08/2007

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