Provider Demographics
NPI:1285102582
Name:JACKSON, STEPHEN LEE (LMFT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 MARYLAND WAY STE 305
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-1035
Mailing Address - Country:US
Mailing Address - Phone:615-293-3780
Mailing Address - Fax:
Practice Address - Street 1:5409 MARYLAND WAY STE 305
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-1035
Practice Address - Country:US
Practice Address - Phone:615-293-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist