Provider Demographics
NPI:1043530991
Name:JACKSON, STACY MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:JACKSON
Other - Last Name:EHLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:291 MADDOX LANE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516
Mailing Address - Country:US
Mailing Address - Phone:785-249-2973
Mailing Address - Fax:
Practice Address - Street 1:3400 PENROSE PL STE 107
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1809
Practice Address - Country:US
Practice Address - Phone:303-443-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010016174122300000X
CODEN.002027911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist