Provider Demographics
NPI:1679721468
Name:JACKMAN, STEPHANIE (LMSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 DEBBIE LN
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-9400
Mailing Address - Country:US
Mailing Address - Phone:585-802-7004
Mailing Address - Fax:
Practice Address - Street 1:360 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1210
Practice Address - Country:US
Practice Address - Phone:585-802-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health