Individual
STEPHANIE ANDREYA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RDH
Contact information
Practice address
801 CRESTVIEW AVE, PROVO, UT 84604-4777
(801) 222-9354
Mailing address
801 CRESTVIEW AVE, PROVO, UT 84604-4777
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
13208
TX
124Q00000X
Dental Hygienist
Primary
5655443-0701
UT
124Q00000X
Dental Hygienist
5908
AZ
Other
Enumeration date
05/21/2007
Last updated
07/08/2007
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