Provider Demographics
NPI:1669971420
Name:DAVIDSON, STEPHANIE (DC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5375 ORTEGA FARMS BLVD UNIT 408
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:414 OLD HARD RD STE 106
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-3407
Practice Address - Country:US
Practice Address - Phone:678-629-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12408111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor