Provider Demographics
NPI:1720421795
Name:JACKSON, ALBERT (AODA)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:AODA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 N 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5750
Mailing Address - Country:US
Mailing Address - Phone:414-301-1163
Mailing Address - Fax:
Practice Address - Street 1:4001 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2530
Practice Address - Country:US
Practice Address - Phone:414-810-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16862-130251S00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)