Healthcare Provider Details

I. General information

NPI: 1518861293
Provider Name (Legal Business Name): STEPHANIE MACK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR
JACKSONVILLE FL
32207-8329
US

IV. Provider business mailing address

850 TOWBIN AVE
LAKEWOOD NJ
08701-5928
US

V. Phone/Fax

Practice location:
  • Phone: 866-523-4268
  • Fax:
Mailing address:
  • Phone: 866-523-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: