| NPI | 1497142459 |
|---|---|
| Former Name | STACEY ANN JACKSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MT APRN-100806) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WY 35557.1401) |
| 363LF0000X Nurse Practitioner, Family (Licence: MT 73310) | |
| Enumeration Date | 2015-04-16 |
| Last Update Date | 2017-10-18 |