Provider Demographics
NPI:1417070921
Name:JACKSON, STEPHANIE (MA, LSSP, LPC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LSSP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1272
Mailing Address - Street 2:
Mailing Address - City:PEARSALL
Mailing Address - State:TX
Mailing Address - Zip Code:78061-1272
Mailing Address - Country:US
Mailing Address - Phone:713-303-7292
Mailing Address - Fax:830-334-3989
Practice Address - Street 1:1214 18TH ST STE B1
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-1753
Practice Address - Country:US
Practice Address - Phone:713-303-7292
Practice Address - Fax:830-584-0633
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20255101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183702301Medicaid