Healthcare Provider Details

I. General information

NPI: 1750291456
Provider Name (Legal Business Name): STEPHANIE KAYLYNN THACKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

IV. Provider business mailing address

3424 CLEARWATER DR
CLARKSVILLE TN
37042-4552
US

V. Phone/Fax

Practice location:
  • Phone: 815-228-5137
  • Fax:
Mailing address:
  • Phone: 815-228-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149027705
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: