Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 1965 | WI |
Y | 103T00000X | Psychologist | 1965 | WI |
NPI | 1013000561 |
---|---|
Provider Name | Dr. Denis Ian Jackson |
First Address | Wauwatosa, WI 53226-3905 |
Second Address | Wauwatosa, WI 53226-3905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 12/11/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39185400 | (05) | WI |