Provider Demographics
NPI:1558135517
Name:JACKSON, STEPHEN (CRS, CPS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRS, CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4635 E STILES ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19137-1119
Mailing Address - Country:US
Mailing Address - Phone:646-469-0120
Mailing Address - Fax:
Practice Address - Street 1:2755 PHILMONT AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-5368
Practice Address - Country:US
Practice Address - Phone:267-297-4116
Practice Address - Fax:215-947-0196
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)