Provider Demographics
NPI:1720524341
Name:JACKSON, NASTASSIA S (LPC-IT)
Entity type:Individual
Prefix:MS
First Name:NASTASSIA
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12922
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-0922
Mailing Address - Country:US
Mailing Address - Phone:414-265-6156
Mailing Address - Fax:
Practice Address - Street 1:6830 W VILLARD AVE STE 190
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:262-320-7886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-07
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2601101YM0800X
101YA0400X, 101YS0200X, 101YS0200X
WI7435101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071680Medicaid