Provider Demographics
NPI:1700381977
Name:NGUYEN, JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 W OKLAHOMA AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4455
Mailing Address - Country:US
Mailing Address - Phone:773-526-8154
Mailing Address - Fax:
Practice Address - Street 1:2025 W OKLAHOMA AVE STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4455
Practice Address - Country:US
Practice Address - Phone:414-389-2790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI73277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program