Provider Demographics
NPI:1407176225
Name:JACKSON, KIMBERLY N (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1627
Mailing Address - Country:US
Mailing Address - Phone:414-406-1406
Mailing Address - Fax:414-933-9533
Practice Address - Street 1:1945 N 17TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-1627
Practice Address - Country:US
Practice Address - Phone:414-406-1406
Practice Address - Fax:414-933-9533
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI170633-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health