Individual
CHARLESETTA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
SAC
Contact information
Practice address
4757 N 76TH ST, MILWAUKEE, WI 53218-4732
(414) 358-4171
(414) 358-5005
Mailing address
4757 N 76TH ST, MILWAUKEE, WI 53218-4732
(414) 358-4171
(414) 358-5005
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
15371-131
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15371-131
DEPARTMENT OF REGULATION & LICENSING
WI
05
—
39178900-31/048
—
WI
Enumeration date
04/22/2008
Last updated
04/22/2008
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