Provider Demographics
NPI:1922679489
Name:JACKSON, BRIANNA SHANICE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BRIANNA
Middle Name:SHANICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 N DR MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-372-8080
Mailing Address - Fax:
Practice Address - Street 1:2555 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:414-562-8084
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program