Provider Demographics
NPI:1013111228
Name:JACKSON, KAREN LYNETTE (LPN)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LYNETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 N 44TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1710
Mailing Address - Country:US
Mailing Address - Phone:414-449-5105
Mailing Address - Fax:
Practice Address - Street 1:2915 N 44TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1710
Practice Address - Country:US
Practice Address - Phone:414-449-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29404-031171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
39877300OtherEDS