Individual
STEPHENIE C JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PMHNP
Contact information
Practice address
119 W SELDEN ST, MATTAPAN, MA 02126-2348
(617) 407-7879
Mailing address
119 W SELDEN ST # 2, MATTAPAN, MA 02126-2348
(617) 407-7879
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
2118
MA
163WA0400X
Addiction (Substance Use Disorder) Registered Nurse
6873
MA
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
RN2288835
MA
Other
Enumeration date
08/06/2021
Last updated
03/25/2025
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