Individual
DR. EDGAR BASIL JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1225 W MITCHELL ST, 223, MILWAUKEE, WI 53204-3383
(414) 383-4455
(414) 727-8730
Mailing address
1225 W MITCHELL ST, 223, MILWAUKEE, WI 53204-3383
(414) 383-4455
(414) 727-8730
Taxonomy
Speciality
Code
Description
License number
State
2084A0401X
Addiction Medicine (Psychiatry & Neurology) Physician
AJ8930984 XJ8930984
WI
2084P0800X
Psychiatry Physician
Primary
13939-20
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1598833410
NPI
WI
05
—
30954700
—
WI
Enumeration date
11/30/2006
Last updated
07/03/2024
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