Healthcare Provider Details

I. General information

NPI: 1003459934
Provider Name (Legal Business Name): STEPHANIE DENISE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22321 W MORNING GLORY ST
BUCKEYE AZ
85326-7181
US

IV. Provider business mailing address

22321 W MORNING GLORY ST
BUCKEYE AZ
85326-7181
US

V. Phone/Fax

Practice location:
  • Phone: 503-209-7572
  • Fax: 602-455-4624
Mailing address:
  • Phone: 503-209-7572
  • Fax: 602-455-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number9911474
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number3311474
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: