Stacey Marie Jackson, PSYD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

08100006337 Issued in VA

Practice address

701 Hospital Loop
Fairchild AFB, WA 99011-8704

Phone

(509) 247-3852

NPI assigned

Aug 14, 2017

Last updated

Aug 15, 2023By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Stacey Marie Ehrenberg Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1502668800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1692057600000",
    "number": "1588189310",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 NEALY BLVD",
            "city": "HAMPTON",
            "state": "VA",
            "postal_code": "236652023"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 HOSPITAL LOOP",
            "city": "FAIRCHILD AFB",
            "state": "WA",
            "postal_code": "990118704",
            "telephone_number": "509-247-3852"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5130 E Clinton Way",
            "address_purpose": "LOCATION",
            "city": "Fresno",
            "state": "CA",
            "postal_code": "937272014",
            "country_code": "US",
            "telephone_number": "552-532-2277",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4881 Sugar Maple Dr",
            "address_purpose": "LOCATION",
            "city": "Wright Patterson AFB",
            "state": "OH",
            "postal_code": "454335529",
            "country_code": "US",
            "telephone_number": "937-257-6877",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4881 Sugar Maple Dr",
            "address_purpose": "LOCATION",
            "city": "Wright Patterson AFB",
            "state": "OH",
            "postal_code": "454335529",
            "country_code": "US",
            "telephone_number": "937-257-6877",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "11 Nealy Blvd",
            "address_purpose": "LOCATION",
            "city": "Hampton",
            "state": "VA",
            "postal_code": "23665",
            "country_code": "US",
            "telephone_number": "757-764-6840",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "51st Medical Group, Unit 2060, APO AP 96278-2060",
            "address_2": "Unit 2060",
            "address_purpose": "LOCATION",
            "city": "APO",
            "state": "AP",
            "postal_code": "962782060",
            "country_code": "KR",
            "telephone_number": "315-784-8717",
            "country_name": "Korea, Republic of",
            "address_type": "FGN"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "STACEY",
        "middle_name": "MARIE",
        "name_prefix": "Dr.",
        "credential": "PSYD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-08-14",
        "last_updated": "2023-08-15",
        "certification_date": "2023-08-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "VA",
            "license": "08100006337",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "STACEY",
            "last_name": "EHRENBERG",
            "middle_name": "MARIE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Nicholas James Graham, IDMT
• Meredith Rose Granholm, IDMT
• Robert Joshua Grant, D.O.
• Kaylene Goldgrabe Hartt, LCSW
• Tonya M Holstein, MSN-FNP-C
• Caden Daniel Jankowski, IDMT
• Garth R Johnson, LCSW
• Wayne Dennis Johnson Jr., IDMT
• Christopher W Kaplan, PAC
• Devin P Kearns, DO

• Clinical Psychologist in Fairchild AFB, WA
• Providers in Fairchild AFB, WA by specialty
• Clinical Psychologist in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.