Jackson, Charlesetta

Jackson, Charlesetta is an individual health care provider with primary practice located at 4757 N 76Th St , Milwaukee WI 53218-4732. She recently has only one registered license in Behavioral Health & Social Service Providers / Addiction (Substance Use Disorder), which is considered as her primary health care specialty. Jackson, Charlesetta can be contacted via phone (414) 358-4171.

Contact Information

Primary practice address
4757 N 76Th St Milwaukee WI 53218-4732
Phone: (414) 358-4171
Fax: (414) 358-5005
Website:
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Health care specialties

SpecialtyCodeLicense #State
Behavioral Health & Social Service Providers / Addiction (Substance Use Disorder) 101YA0400X 15371-131 Wisconsin

Profile Details

NPI number 1922273879
LBN Legal business name Jackson, Charlesetta
Credentials SAC
Entity Individual
Sole proprietor 1 No
Enumeration date Apr 22nd, 2008
Last updated Apr 22nd, 2008 - about 18 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1922273879 NPPES
Wisconsin Other 15371-131 DEPARTMENT OF REGULATION & LICENSING
Wisconsin MEDICAID 39178900-31/048 DEPARTMENT OF REGULATION & LICENSING

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