Provider Demographics
NPI:1538870944
Name:JACKSON, STENNEN N
Entity type:Individual
Prefix:
First Name:STENNEN
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 W CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4946
Mailing Address - Country:US
Mailing Address - Phone:414-539-9903
Mailing Address - Fax:
Practice Address - Street 1:2607 W CUSTER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4946
Practice Address - Country:US
Practice Address - Phone:414-539-9903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)