Provider Demographics
NPI:1710681770
Name:HARVEY, JACKSON PHILIP
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:PHILIP
Last Name:HARVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BROOKE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9360
Mailing Address - Country:US
Mailing Address - Phone:630-338-6082
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-1195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program