Provider Demographics
NPI:1427722917
Name:JACKSON, STEPHENIE C (PMHNP)
Entity type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:
Credentials:PMHNP
Other - Prefix:
Other - First Name:STEPHENIE
Other - Middle Name:
Other - Last Name:JACKSON-WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP
Mailing Address - Street 1:119 W SELDEN ST # 2
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2348
Mailing Address - Country:US
Mailing Address - Phone:617-407-7879
Mailing Address - Fax:
Practice Address - Street 1:119 W SELDEN ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2348
Practice Address - Country:US
Practice Address - Phone:617-407-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2118101YA0400X
MA6873163WA0400X
MARN2288835363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)