MEDICARE: MRS. STEPHANIE PERRY JACKSON CFNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R862558	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821097858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE PERRY JACKSON CFNP

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39130-0417
Country	:	US
Telephone Number	:	601-720-5303
Fax Number	:	601-510-9643

Provider Business Practice Location Address
First Line	:	162 FEATHER LN
Second Line	:	SUITE E
City	:	CANTON
State	:	MS
Zip	:	39046-8510
Country	:	US
Telephone Number	:	601-859-0140
Fax Number	:	601-510-9643

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	10/20/2015

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