Provider Demographics
NPI:1891324430
Name:JACKSON, STEFANIE CHARISSE (LMFT)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:CHARISSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9846 LORI RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-6695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9846 LORI RD STE 201
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6695
Practice Address - Country:US
Practice Address - Phone:404-372-5538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001609106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist