Basic Information
| Provider Information | |||||||||
| NPI: | 1003459934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 22321 W MORNING GLORY ST | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853267181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032097572 | ||||||||
| FaxNumber: | 6024554624 | ||||||||
| Practice Location | |||||||||
| Address1: | 22321 W MORNING GLORY ST | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853267181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032097572 | ||||||||
| FaxNumber: | 6024554624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2019 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | 9911474 | AZ | Y | Agencies | Foster Care Agency | 385HR2055X | 3311474 | AZ | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child |
No ID Information.