Organization
JACKSONSCOTT2
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LATASHA JACKSON LPN (LPN)
(414) 517-2825
Entity
Organization
Contact information
Practice address
4573 N. 22ND STREET, MILWAUKEE, WI 53209
(414) 517-2825
Mailing address
4573 N 22ND ST, MILWAUKEE, WI 53209-6309
(414) 517-2825
Taxonomy
Speciality
Code
Description
License number
State
3140N1450X
Pediatric Skilled Nursing Facility
Primary
317445-31
WI
Other
Enumeration date
02/07/2017
Last updated
02/07/2017
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