Individual
PETER C. JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSYD
Contact information
Practice address
700 RAY O VAC DR, SUITE 220, MADISON, WI 53711-2479
(608) 276-9191
(608) 276-9144
Mailing address
3330 UNIVERSITY AVE, STE 312, MADISON, WI 53705-2167
(608) 276-9191
(608) 276-9144
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
1805-057
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
39105300
—
WI
Enumeration date
12/27/2006
Last updated
01/22/2019
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