Provider Demographics
NPI:1255955464
Name:JACKSON, STEPHANE LEA (LMT, CCT)
Entity type:Individual
Prefix:
First Name:STEPHANE
Middle Name:LEA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT, CCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 OLD SPRING HOUSE LN STE 114
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6213
Mailing Address - Country:US
Mailing Address - Phone:770-806-9048
Mailing Address - Fax:
Practice Address - Street 1:1770 OLD SPRING HOUSE LN STE 114
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6213
Practice Address - Country:US
Practice Address - Phone:770-806-9048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007289225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist