Edgar Basil Jackson, MD

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

13939-20 Issued in WI

Practice address

1225 W Mitchell St
223
Milwaukee, WI 53204-3383

Phone

(414) 383-4455

Fax

(414) 727-8730

NPI assigned

Nov 30, 2006

Last updated

Jul 3, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Milwaukee Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Milwaukee, WI
  • NPI 1518005818
  Medicare reassignment NPD
• Milwaukee Health Services Inc

  dba Martin Luther King Heritage Health Center

  • Case Management Agency
  • Milwaukee, WI
  • NPI 1346657442
  NPD
• Milwaukee Health Services, Inc.

  dba Martin Luther King Heritage Health Center

  • Clinic Pharmacy
  • Milwaukee, WI
  • NPI 1821028887
  NPD
• Achievement Associates, LTD

  • Clinical Psychologist
  • Mequon, WI
  • NPI 1154365971
  NPD (past)
• Associated Counseling and Recovery Center LLC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Fond Du Lac, WI
  • NPI 1487712519
  NPD (past)
• Dodge County Medical Facilities

  • Skilled Nursing Facility
  • Juneau, WI
  • NPI 1407067945
  NPD (past)
• Horizon Healthcare, Inc

  • Mental Health Counselor
  • Greenfield, WI
  • NPI 1043234628
  NPD (past)
• Horizon Healthcare, Inc

  • Multi-Specialty Clinic/Center
  • Milwaukee, WI
  • NPI 1225052830
  NPD (past)
• Miracle Counseling LLC

  dba Miracle Counseling and Life Coaching, LLC

  • Mental Health Counselor
  • Milwaukee, WI
  • NPI 1942682620
  NPD (past)
• STCH de Pere Wi Opco LLC

  dba St Croix Hospice

  • Community Based Hospice Care Agency
  • Green Bay, WI
  • NPI 1487378956
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164844800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1719964800000",
    "number": "1598833410",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1225 W MITCHELL ST",
            "address_2": "223",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532043383",
            "telephone_number": "414-383-4455",
            "fax_number": "414-727-8730"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1225 W MITCHELL ST",
            "address_2": "223",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532043383",
            "telephone_number": "414-383-4455",
            "fax_number": "414-727-8730"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "8440 W National Ave",
            "address_purpose": "LOCATION",
            "city": "Milwaukee",
            "state": "WI",
            "postal_code": "532271734",
            "country_code": "US",
            "telephone_number": "414-405-1682",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2555 N Dr Martin Luther King Jr Dr",
            "address_purpose": "LOCATION",
            "city": "Milwaukee",
            "state": "WI",
            "postal_code": "532122709",
            "country_code": "US",
            "telephone_number": "414-372-8080",
            "fax_number": "414-267-8570",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "8200 W Silver Spring Dr",
            "address_purpose": "LOCATION",
            "city": "Milwaukee",
            "state": "WI",
            "postal_code": "532182552",
            "country_code": "US",
            "telephone_number": "414-760-3900",
            "fax_number": "414-464-6321",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "EDGAR",
        "middle_name": "BASIL",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-30",
        "last_updated": "2024-07-03",
        "certification_date": "2024-07-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084A0401X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Addiction Medicine",
            "state": "WI",
            "license": "AJ8930984 XJ8930984",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "WI",
            "license": "13939-20",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "30954700",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1598833410",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Charlesetta Jackson, SAC
• Courtney Moore Jackson, D.D.S.
• Darneshia Jackson
• David B. Jackson, M.D.
• Donna Jackson, LPN
• Gemontasia Kiriaqua Jackson
• Hannah Nicole Jackson, DO
• Hillary Diane Jackson, DPT
• Jeffrey L Jackson, MD
• Jessica M Jackson, APNP

• Psychiatry Physician in Milwaukee, WI
• Providers in Milwaukee, WI by specialty
• Psychiatry Physician in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.