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General NPI Number Information
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NPI Number | 1770248668
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Entity Type | Individual
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Provider Name | STACIE JACKSON PA
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Gender | Female
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Dates
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Enumeration Date | 11/04/2021
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Last Update Date | 03/10/2025
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Provider Practice Location Address
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Address Line | 3627 UNIVERSITY BLVD S STE 550
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City | JACKSONVILLE
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State | FL
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Zip | 32216-7401
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Country | US
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Telephone | 904-379-5986
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 370
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City | FORTSON
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State | GA
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Zip | 31808-0370
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Country | US
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Telephone | 706-494-3171
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 9115246
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA9115246
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License Number State | FL
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