Provider Demographics
NPI:1083342315
Name:JACKSON, OSTASSIA
Entity Type:Individual
Prefix:
First Name:OSTASSIA
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 1:11431 N PORT WASHINGTON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3462
Mailing Address - Country:US
Mailing Address - Phone:414-319-9195
Mailing Address - Fax:
Practice Address - Street 1:11431 N PORT WASHINGTON RD STE 206
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3462
Practice Address - Country:US
Practice Address - Phone:414-319-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No177F00000XOther Service ProvidersLodging
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care