Individual
MS. NASTASSIA S JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPC-IT
Contact information
Practice address
6830 W VILLARD AVE STE 190, MILWAUKEE, WI 53218
(262) 320-7886
Mailing address
PO BOX 12922, MILWAUKEE, WI 53212-0922
(414) 265-6156
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
2601
WI
101YM0800X
Mental Health Counselor
Primary
7435
WI
101YS0200X
School Counselor
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100071680
—
WI
Enumeration date
01/07/2017
Last updated
06/18/2019
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