Healthcare Provider Details

I. General information

NPI: 1073258380
Provider Name (Legal Business Name): STEPHANIE D JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W TEMPLE AVE STE 1500
EFFINGHAM IL
62401-2121
US

IV. Provider business mailing address

900 W TEMPLE AVE
EFFINGHAM IL
62401-2121
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-0458
  • Fax:
Mailing address:
  • Phone: 217-347-0458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.025152
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: