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General NPI Number Information
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NPI Number | 1891324430
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Entity Type | Individual
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Provider Name | STEFANIE CHARISSE JACKSON LMFT
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Gender | Female
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Dates
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Enumeration Date | 04/06/2020
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 260 PEACHTREE ST NW STE 2200
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City | ATLANTA
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State | GA
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Zip | 30303-1292
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Country | US
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Telephone | 301-392-7779
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Fax |
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Provider Business Mailing Address
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Address Line | 9846 LORI RD STE 201
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City | CHESTERFIELD
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State | VA
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Zip | 23832-6695
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Country | US
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Telephone |
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 0717001609
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT001862
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | TPMF1187
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License Number State | FL
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