Provider Demographics
NPI:1659562692
Name:JACKSON, STACEY LAJUNE
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LAJUNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:LAJUNE
Other - Last Name:JACKSON-LAMPLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:110 EAGLES WALK
Mailing Address - Street 2:STE. 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7204
Mailing Address - Country:US
Mailing Address - Phone:770-507-6044
Mailing Address - Fax:770-507-5284
Practice Address - Street 1:110 EAGLES WALK
Practice Address - Street 2:STE. 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7204
Practice Address - Country:US
Practice Address - Phone:770-507-6044
Practice Address - Fax:770-507-5284
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003073103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling