Provider Demographics
NPI:1598555393
Name:JACKSON, STEPHANIE L (RN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 GAGNON RD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-9516
Mailing Address - Country:US
Mailing Address - Phone:907-202-4501
Mailing Address - Fax:
Practice Address - Street 1:223 E 4TH ST STE 12
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3000
Practice Address - Country:US
Practice Address - Phone:907-202-4501
Practice Address - Fax:907-202-4501
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61330864163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse