Provider Demographics
NPI:1629446760
Name:STEVENSON, JACRISSA S (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACRISSA
Middle Name:S
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 STONECROP DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-9054
Mailing Address - Country:US
Mailing Address - Phone:859-533-4470
Mailing Address - Fax:
Practice Address - Street 1:4750 HARTLAND PKWY STE 248
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-1561
Practice Address - Country:US
Practice Address - Phone:859-436-9618
Practice Address - Fax:859-201-1361
Is Sole Proprietor?:No
Enumeration Date:2015-09-07
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY73451041C0700X
KY2543541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid