MEDICARE: GEMONTASIA KIRIAQUA JACKSON

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	246RP1900X	Phlebotomy Technician

General Provider Information

NPI Number	:	1629841200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEMONTASIA KIRIAQUA JACKSON

Provider Business Mailing Address
First Line	:	2872 N 59TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1504
Country	:	US
Telephone Number	:	414-939-5802
Fax Number	:

Provider Business Practice Location Address
First Line	:	2872 N 59TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1504
Country	:	US
Telephone Number	:	414-939-5802
Fax Number	:

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

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	12/13/2023

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