MEDICARE: STEFANIE CHARISSE JACKSON LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	0717001609	VA
2	106H00000X	Marriage & Family Therapist	MFT001862	GA
3	106H00000X	Marriage & Family Therapist	TPMF1187	FL

General Provider Information

NPI Number	:	1891324430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEFANIE CHARISSE JACKSON LMFT

Provider Business Mailing Address
First Line	:	9846 LORI RD STE 201
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-6695
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 PEACHTREE ST NW STE 2200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30303-1292
Country	:	US
Telephone Number	:	301-392-7779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2020
Last Update Date	:	12/01/2025

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