Provider Demographics
NPI:1245327527
Name:JACKSON, STACEY N (LCSW PIP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW PIP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:N
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW PIP
Mailing Address - Street 1:1615 KATHY LN SW
Mailing Address - Street 2:PO BX 2240
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-1026
Mailing Address - Country:US
Mailing Address - Phone:256-306-4128
Mailing Address - Fax:256-432-2015
Practice Address - Street 1:1615 KATHY LN SW
Practice Address - Street 2:PO BX 2240
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-1026
Practice Address - Country:US
Practice Address - Phone:256-306-4128
Practice Address - Fax:256-432-2015
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1798-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker