Provider Demographics
NPI:1255512984
Name:JACKSON, STEPHANIE BRAZEAL (NP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:BRAZEAL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:CECILIA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:711 TRESTLE RD
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3465
Mailing Address - Country:US
Mailing Address - Phone:770-914-5934
Mailing Address - Fax:
Practice Address - Street 1:711 TRESTLE RD
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3465
Practice Address - Country:US
Practice Address - Phone:770-914-5934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN071218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily