Provider Demographics
NPI:1144798950
Name:JACKSON, STEPHANIE A (OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 OPEQUON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-5130
Mailing Address - Country:US
Mailing Address - Phone:540-664-7622
Mailing Address - Fax:
Practice Address - Street 1:151 SKYLINE VISTA DR
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-8219
Practice Address - Country:US
Practice Address - Phone:540-631-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007678225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist