MEDICARE: ALBERT JACKSON AODA

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	251S00000X	Community/Behavioral Health Agency	16862-130	WI
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	16862-130	WI

General Provider Information

NPI Number	:	1720421795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALBERT JACKSON AODA

Provider Business Mailing Address
First Line	:	4950 N 21ST STREET
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-5750
Country	:	US
Telephone Number	:	414-301-1163
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2530
Country	:	US
Telephone Number	:	414-810-6691
Fax Number	:

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

Provider Enumeration Date	:	04/09/2013
Last Update Date	:	04/09/2013

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