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General NPI Number Information
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NPI Number | 1245327527
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Entity Type | Individual
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Provider Name | STACEY N JACKSON L.C.S.W. P.I.P
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Gender | Female
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 08/05/2011
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Provider Practice Location Address
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Address Line | 1615 KATHY LN SW PO BX 2240
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City | DECATUR
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State | AL
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Zip | 35603-1026
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Country | US
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Telephone | 256-306-4128
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Fax | 256-432-2015
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Provider Business Mailing Address
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Address Line | 1615 KATHY LN SW PO BX 2240
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City | DECATUR
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State | AL
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Zip | 35603-1026
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Country | US
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Telephone | 256-306-4128
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Fax | 256-432-2015
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 1798-C
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License Number State | AL
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