Provider Demographics
NPI:1689189953
Name:STEMBRIDGE, JACKSON COLE
Entity type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:COLE
Last Name:STEMBRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 YELLOWHOUSE CIR APT A
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-4899
Mailing Address - Country:US
Mailing Address - Phone:469-855-7059
Mailing Address - Fax:
Practice Address - Street 1:1815 YELLOWHOUSE CIR APT A
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-4899
Practice Address - Country:US
Practice Address - Phone:469-855-7059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer