Provider Demographics
NPI:1477399947
Name:PICKETT, STEPHANIE KEIKO
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KEIKO
Last Name:PICKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464099 STATE ROAD 200 STE 2
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-6460
Mailing Address - Country:US
Mailing Address - Phone:904-875-4461
Mailing Address - Fax:
Practice Address - Street 1:464099 STATE ROAD 200 STE 2
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6460
Practice Address - Country:US
Practice Address - Phone:904-875-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician