Provider Demographics
NPI:1568262061
Name:JACKSON, STACEY LORRAINNE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LORRAINNE
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MARTINVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3512
Mailing Address - Country:US
Mailing Address - Phone:402-677-8462
Mailing Address - Fax:
Practice Address - Street 1:44 MARTINVIEW RD APT 2
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3512
Practice Address - Country:US
Practice Address - Phone:402-677-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty