1831239847 NPI number — DR. STACEY LEE JACOBS D.D.S.

Table of content: DR. STACEY LEE JACOBS D.D.S. (NPI 1831239847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831239847 NPI number — DR. STACEY LEE JACOBS D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
STACEY
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACOBS
Provider Other First Name:
STACEY
Provider Other Middle Name:
GILLIAM
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1831239847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1402 WOODLAND COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONDO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78861-1000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-426-1977
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1313 LORENZO
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
CASTROVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78009-4532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-538-2236
Provider Business Practice Location Address Fax Number:
830-931-2007
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22461 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1781346 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com