Provider Demographics
NPI:1730389990
Name:ROGERS, STEPHANIE JACKSON (MA, CCC-A)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JACKSON
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17167
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-7167
Mailing Address - Country:US
Mailing Address - Phone:601-261-5995
Mailing Address - Fax:601-261-5335
Practice Address - Street 1:3901 HARDY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1636
Practice Address - Country:US
Practice Address - Phone:601-261-5995
Practice Address - Fax:601-261-5335
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA9340237600000X
AL1021A237600000X
MSA3163237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I640023OtherPTAN
MS512I640023OtherPTAN