Individual
JIHAD JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
5427 N 91ST ST APT 1, MILWAUKEE, WI 53225-3427
(262) 613-2960
Mailing address
2200 N COMMERCE ST, MILWAUKEE, WI 53212-3497
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
81-4901700
—
WI
Enumeration date
06/05/2017
Last updated
06/05/2017
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