Provider Demographics
NPI:1649011453
Name:JACKSON, STEPHANIE ANN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:JACKSON
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 1:10715 55TH CT E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-4499
Mailing Address - Country:US
Mailing Address - Phone:301-785-4412
Mailing Address - Fax:
Practice Address - Street 1:6979 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8411
Practice Address - Country:US
Practice Address - Phone:301-785-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician