Provider Demographics
NPI:1730281429
Name:JACKSON, JEFFREY A (PAC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:3703 OAKWOOD HILLS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4458
Practice Address - Country:US
Practice Address - Phone:534-444-4562
Practice Address - Fax:534-444-4563
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIAPPRMedicaid
WIAPPRMedicaid
S82435Medicare UPIN