Provider Demographics
NPI:1942868013
Name:JACKSON, STACY HARKINS (LICSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:HARKINS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36203-3705
Mailing Address - Country:US
Mailing Address - Phone:256-624-7045
Mailing Address - Fax:
Practice Address - Street 1:1812 WILMER AVE STE A
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-3830
Practice Address - Country:US
Practice Address - Phone:256-624-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4288C101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health