Provider Demographics
NPI:1013000561
Name:JACKSON, DENIS IAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENIS
Middle Name:IAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11931 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3905
Mailing Address - Country:US
Mailing Address - Phone:414-276-8669
Mailing Address - Fax:414-276-1266
Practice Address - Street 1:11931 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3905
Practice Address - Country:US
Practice Address - Phone:414-276-8669
Practice Address - Fax:414-276-1266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1965103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39185400Medicaid