Provider Demographics
NPI:1073100962
Name:JACKSON, DARNESHIA
Entity Type:Individual
Prefix:
First Name:DARNESHIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 N 67TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3017
Mailing Address - Country:US
Mailing Address - Phone:414-323-3792
Mailing Address - Fax:
Practice Address - Street 1:5220 N 67TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3017
Practice Address - Country:US
Practice Address - Phone:414-323-3792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-25
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI854230292Medicaid