Provider Demographics
NPI:1013177872
Name:JACKSON, STEPHANIE COLLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:COLLEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:COLLEEN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:275 10TH ST SE STE 3320
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2450
Mailing Address - Country:US
Mailing Address - Phone:319-398-1721
Mailing Address - Fax:
Practice Address - Street 1:275 10TH ST SE STE 3320
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2450
Practice Address - Country:US
Practice Address - Phone:319-398-1721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12520712084N0400X
NV149222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV14922OtherMEDICAL LICENSE
NVFS4122191OtherDEA