| Doctor Name: | MR. NYLES ANTONY JACKSON |
| NPI Number: | 1053637629 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MSW, APSW, SAC-IT |
| License Number: | 15877-130 |
| Business Practice Address: | 4109 67th St Kenosha, WI - 531423836 |
| Business Phone Number: | 2626529830 |
| Business Fax Number: | 2626522931 |
| Mailing Address: | 4109 67th St, KENOSHA |
| State: | WI |
| Postal Code: | 531423836 |
| Phone Number: | 2626529830 |
| Fax Number: | 2626522931 |
| NPI Enumeration Date: | 04/07/2010 |
| NPI Last Update Date: | 04/07/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 15877-130 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |