Provider Demographics
NPI:1275926503
Name:JACKSON, STEPHEN (RDCS, RVT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RDCS, RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 SAWGRASS LAKE CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2935
Mailing Address - Country:US
Mailing Address - Phone:202-277-1063
Mailing Address - Fax:
Practice Address - Street 1:2577 SAWGRASS LAKE CT
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2935
Practice Address - Country:US
Practice Address - Phone:202-277-1063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL105942246XC2903X, 246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular Specialist