Healthcare Provider Details

I. General information

NPI: 1033375043
Provider Name (Legal Business Name): STEPHANIE J. JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR ROC 4270
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7208
  • Fax: 317-274-7227
Mailing address:
  • Phone: 317-274-1201
  • Fax: 317-278-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125053014
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number01071127
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number01071127A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: