| Doctor Name: | DR. EDGAR BASIL JACKSON |
| NPI Number: | 1598833410 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | AJ8930984 XJ8930984 |
| Business Practice Address: | 1225 W Mitchell St 223 Milwaukee, WI - 532043383 |
| Business Phone Number: | 4143834455 |
| Business Fax Number: | 4147278730 |
| Mailing Address: | 1225 W Mitchell St, 223 MILWAUKEE |
| State: | WI |
| Postal Code: | 532043383 |
| Phone Number: | 4143834455 |
| Fax Number: | 4147278730 |
| NPI Enumeration Date: | 11/30/2006 |
| NPI Last Update Date: | 05/30/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2084A0401X |
| License Number: | AJ8930984 XJ8930984 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | WI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Psychiatry & Neurology |
| Taxonomy Specialization: | Addiction Medicine |
| Taxonomy Definition: | A doctor of osteopathy board eligible/certified in the field of Psychiatry by the American Osteopathic Board of Neurology and Psychiatry is able to obtain a Certificate of Added Qualifications in the field of Addiction Medicine |