Provider Demographics
NPI:1710463419
Name:JACKSON, JOYCE R
Entity Type:Individual
Prefix:MISS
First Name:JOYCE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 N 76TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3057
Mailing Address - Country:US
Mailing Address - Phone:414-484-2544
Mailing Address - Fax:
Practice Address - Street 1:3533 N 76TH ST APT 3
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3057
Practice Address - Country:US
Practice Address - Phone:414-484-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI219422-30163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$Medicaid