Provider Demographics
NPI:1982971479
Name:JACKSON, JULIE M (NP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 AMERICAN AVE
Mailing Address - Street 2:INTERVENTIONAL PAIN
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189
Mailing Address - Country:US
Mailing Address - Phone:262-928-8672
Mailing Address - Fax:
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:INTERVENTIONAL PAIN
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-8672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4653-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health