Provider Demographics
NPI:1063839918
Name:JACKSON, JESSICA M (APNP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:TICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF CARDIOOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6777
Mailing Address - Fax:414-955-6203
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF CARDIOOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6777
Practice Address - Fax:414-955-6203
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI175848-30363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063839918Medicaid