Provider Demographics
NPI:1134461361
Name:JACKSON, STEPHANIE K (LMP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S MISSION ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3049
Mailing Address - Country:US
Mailing Address - Phone:253-370-7445
Mailing Address - Fax:
Practice Address - Street 1:1513 SLEEPY HOLLOW RD UNIT A
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-9132
Practice Address - Country:US
Practice Address - Phone:253-370-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist