Basic Information
| Provider Information | |||||||||
| NPI: | 1598833410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | BASIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 W MITCHELL ST | ||||||||
| Address2: | 223 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4147278730 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 W MITCHELL ST | ||||||||
| Address2: | 223 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4147278730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | AJ8930984 XJ8930984 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | 13939 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 30954700 | 05 | WI | MEDICAID | 1598833410 | 01 | WI | NPI | OTHER |