Provider Demographics
NPI:1346204427
Name:JACKSON, STEFANIE M (ARNP)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0484
Mailing Address - Country:US
Mailing Address - Phone:386-755-0421
Mailing Address - Fax:386-487-1234
Practice Address - Street 1:1289 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0484
Practice Address - Country:US
Practice Address - Phone:386-755-0421
Practice Address - Fax:386-487-1234
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2620432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP2620432OtherMEDICAL LICENSE
FL275262OtherAVMED
FL363L00000XOtherTAXONOMY CODE
FLDE000ZOtherMEDICARE PTAN
FLS94534Medicare UPIN