Provider Demographics
NPI:1992204796
Name:JACKSON, JADE C (APNP-C)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1469
Mailing Address - Country:US
Mailing Address - Phone:920-492-8293
Mailing Address - Fax:855-739-0754
Practice Address - Street 1:125 S 84TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1469
Practice Address - Country:US
Practice Address - Phone:920-492-8293
Practice Address - Fax:855-739-0754
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI197335163W00000X
WI8247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse