Provider Demographics
NPI:1477849826
Name:JACKSON, STACEY JO (BHRS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:JO
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 421
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-9204
Mailing Address - Country:US
Mailing Address - Phone:580-306-0303
Mailing Address - Fax:
Practice Address - Street 1:17 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4625
Practice Address - Country:US
Practice Address - Phone:580-306-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist