Provider Demographics
NPI:1619107331
Name:STACK, JESSICA LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:STACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W 25TH ST FL 10
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7470
Mailing Address - Country:US
Mailing Address - Phone:212-335-2100
Mailing Address - Fax:646-775-4142
Practice Address - Street 1:138 W 25TH ST FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7470
Practice Address - Country:US
Practice Address - Phone:212-335-2100
Practice Address - Fax:646-775-4142
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP017392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry