Provider Demographics
NPI:1407161599
Name:JACKSON, VICKIE LEE
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:VICKIE
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:7809 W BECKETT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-5320
Mailing Address - Country:US
Mailing Address - Phone:414-535-9892
Mailing Address - Fax:414-535-9892
Practice Address - Street 1:7809 W BECKETT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-5320
Practice Address - Country:US
Practice Address - Phone:414-535-9892
Practice Address - Fax:414-535-9892
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI564-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health