Provider Demographics
NPI:1487922837
Name:JACKSON, SHAWN A (SAC-IT)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10532 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5563
Mailing Address - Country:US
Mailing Address - Phone:262-242-3810
Mailing Address - Fax:262-242-3816
Practice Address - Street 1:10532 N. PORT WASHINGTON RD.
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-242-3810
Practice Address - Fax:262-242-3816
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16299-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)