Provider Demographics
NPI:1598833410
Name:JACKSON, EDGAR BASIL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:BASIL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1225 W MITCHELL ST
Mailing Address - Street 2:223
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3383
Mailing Address - Country:US
Mailing Address - Phone:414-383-4455
Mailing Address - Fax:414-727-8730
Practice Address - Street 1:1225 W MITCHELL ST
Practice Address - Street 2:223
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3383
Practice Address - Country:US
Practice Address - Phone:414-383-4455
Practice Address - Fax:414-727-8730
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIAJ8930984 XJ89309842084A0401X
WI139392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1598833410OtherNPI
WI30954700Medicaid
WI30954700Medicaid
WI1598833410OtherNPI