Healthcare Provider Details

I. General information

NPI: 1518896570
Provider Name (Legal Business Name): STEPHANIE DANIELLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24898 SPILLERS RANCH RD
DENHAM SPRINGS LA
70726-6801
US

IV. Provider business mailing address

24898 SPILLERS RANCH RD
DENHAM SPRINGS LA
70726-6801
US

V. Phone/Fax

Practice location:
  • Phone: 225-910-3319
  • Fax:
Mailing address:
  • Phone: 225-910-3319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number007667754
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: