Provider Demographics
NPI:1376012609
Name:JACKSON, STACY ANN (N/A)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 STATE ST STE 750
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5861
Mailing Address - Country:US
Mailing Address - Phone:971-273-7502
Mailing Address - Fax:
Practice Address - Street 1:3762 AMBER ST NE APT 102
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6883
Practice Address - Country:US
Practice Address - Phone:971-239-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst