Provider Demographics
NPI:1366425373
Name:STEWART ANDERSON, JACALYN MARY (RN)
Entity type:Individual
Prefix:MRS
First Name:JACALYN
Middle Name:MARY
Last Name:STEWART ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5726 S 113TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1806
Mailing Address - Country:US
Mailing Address - Phone:414-425-8931
Mailing Address - Fax:
Practice Address - Street 1:16265 CUMBERLAND TRL
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2212
Practice Address - Country:US
Practice Address - Phone:262-790-0079
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39890700Medicaid