Provider Demographics
NPI:1902559784
Name:JACKSON, STEPHANIE D (RN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:DENISE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4605 CHESTNUT OAK ST
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9408
Mailing Address - Country:US
Mailing Address - Phone:423-227-8576
Mailing Address - Fax:
Practice Address - Street 1:4605 CHESTNUT OAK ST
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-9408
Practice Address - Country:US
Practice Address - Phone:423-227-8576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210155163WC0400X, 163WE0900X, 163WD0400X, 163WA2000X, 163WN1003X, 163WP0000X, 163WW0000X, 163WX0800X, 163WX1500X, 163W00000X
GARN163WH0200X, 163WC1500X, 163WH1000X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WP0000XNursing Service ProvidersRegistered NursePain Management
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care