Provider Demographics
NPI:1003628603
Name:JACKSON, JENNA MARIE (SAC-IT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N961 FOX RUN LN APT 5
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9587
Mailing Address - Country:US
Mailing Address - Phone:262-370-1041
Mailing Address - Fax:
Practice Address - Street 1:1501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2461
Practice Address - Country:US
Practice Address - Phone:262-548-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20708-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)