Provider Demographics
NPI:1972922706
Name:JACKOWIAK, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:JACKOWIAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:MICHAEL
Other - Last Name:JACKOWIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5200
Mailing Address - Fax:414-259-0469
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:414-805-5200
Practice Address - Fax:414-259-0469
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI726582084N0400X
MI43011140442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1972922706Medicaid