Provider Demographics
NPI:1942796552
Name:STEWART, JACKIE LEE (CMS)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LEE
Last Name:STEWART
Suffix:
Gender:M
Credentials:CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 WASHINGTON BLVD S
Mailing Address - Street 2:
Mailing Address - City:WEST PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45663-5893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14574 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9373
Practice Address - Country:US
Practice Address - Phone:740-821-1562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)