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General NPI Number Information
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NPI Number | 1033375043
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Entity Type | Individual
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Provider Name | STEPHANIE J. JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/30/2008
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 705 RILEY HOSPITAL DR ROC 4270
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-5109
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Country | US
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Telephone | 317-274-7208
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Fax | 317-274-7227
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Provider Business Mailing Address
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Address Line | PO BOX 1026
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City | INDIANAPOLIS
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State | IN
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Zip | 46206-1026
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Country | US
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Telephone | 317-274-1201
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Fax | 317-278-9905
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 125053014
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 2084N0402X
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Taxonomy Name | Neurology with Special Qualifications in Child Neurology Physician
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License Number | 01071127
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 2080S0012X
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Taxonomy Name | Pediatric Sleep Medicine Physician
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License Number | 01071127A
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License Number State | IN
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