Provider Demographics
NPI:1497142459
Name:JACKSON, STACEY ANN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 CENTRAL AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102
Mailing Address - Country:US
Mailing Address - Phone:406-869-1066
Mailing Address - Fax:
Practice Address - Street 1:1010 CENTRAL AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-869-1066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY35557.1401363LF0000X
MT73310363LF0000X
MTAPRN-100806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily