Provider Demographics
NPI:1194372243
Name:JACKSON, JOSHUA RASHAD SR
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:RASHAD
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N67W13215 DAYLILY DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0504
Mailing Address - Country:US
Mailing Address - Phone:414-233-5907
Mailing Address - Fax:262-345-5550
Practice Address - Street 1:6340 N 84TH ST APT 5
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-1972
Practice Address - Country:US
Practice Address - Phone:414-233-5907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI832046773Medicaid