Provider Demographics
NPI:1134662646
Name:JACKSON, STEVIE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:STEVIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 SIMPSON HIGHWAY 149
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3439
Mailing Address - Country:US
Mailing Address - Phone:601-894-6669
Mailing Address - Fax:601-894-4721
Practice Address - Street 1:1007 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2603
Practice Address - Country:US
Practice Address - Phone:601-847-3712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily