Provider Demographics
NPI:1164019774
Name:JACKSON, STEPHANIE KAY
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:KAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3094
Mailing Address - Country:US
Mailing Address - Phone:863-293-1191
Mailing Address - Fax:
Practice Address - Street 1:199 AVENUE B NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4546
Practice Address - Country:US
Practice Address - Phone:863-293-1191
Practice Address - Fax:863-401-8058
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9260330163W00000X
FLAPRN11011834363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care