1245327527 NPI number — STACEY N JACKSON L.C.S.W. P.I.P

Table of content: STACEY N JACKSON L.C.S.W. P.I.P (NPI 1245327527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245327527 NPI number — STACEY N JACKSON L.C.S.W. P.I.P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
STACEY
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W. P.I.P
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
STACEY
Provider Other Middle Name:
N.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.C.S.W. P.I.P.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245327527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1615 KATHY LN SW
Provider Second Line Business Mailing Address:
PO BX 2240
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35603-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-306-4128
Provider Business Mailing Address Fax Number:
256-432-2015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 KATHY LN SW
Provider Second Line Business Practice Location Address:
PO BX 2240
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35603-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-306-4128
Provider Business Practice Location Address Fax Number:
256-432-2015
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  1798-C , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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