Provider Demographics
NPI:1376094938
Name:JACKSON, STEPHANY (LCSWA)
Entity Type:Individual
Prefix:
First Name:STEPHANY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7009 KALMIA LN
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-9278
Mailing Address - Country:US
Mailing Address - Phone:910-568-2316
Mailing Address - Fax:
Practice Address - Street 1:3125 POPLARWOOD CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1084
Practice Address - Country:US
Practice Address - Phone:919-790-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0102151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical