Provider Demographics
NPI:1528010345
Name:STEPHENSON, JACKIE LYN (CNM)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYN
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43624-1120
Mailing Address - Country:US
Mailing Address - Phone:419-251-2673
Mailing Address - Fax:419-251-0916
Practice Address - Street 1:2702 NAVARRE AVE STE 305
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3224
Practice Address - Country:US
Practice Address - Phone:419-691-8000
Practice Address - Fax:419-693-0111
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNM07221367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife