Provider Demographics
NPI:1417635665
Name:STACKO, JESSICA JOAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:JOAN
Last Name:STACKO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E 53RD ST STE 734
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4575
Mailing Address - Country:US
Mailing Address - Phone:773-643-6006
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST STE 734
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4575
Practice Address - Country:US
Practice Address - Phone:773-643-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190344331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice