Provider Demographics
NPI:1861462509
Name:JACKSON, STEPHANIE L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W UTOPIA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:623-434-6200
Mailing Address - Fax:623-434-6164
Practice Address - Street 1:10900 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 603
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5216
Practice Address - Country:US
Practice Address - Phone:480-882-7470
Practice Address - Fax:480-922-2472
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23663207R00000X
AZ51415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286902Medicaid
AZ120461Medicaid
R146667Medicare PIN
OR286902Medicaid
AZZ187067Medicare PIN