Provider Demographics
NPI:1750010054
Name:STACY, JONATHAN N
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:N
Last Name:STACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DANIEL BOONE PLZ
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-5335
Mailing Address - Country:US
Mailing Address - Phone:606-487-0244
Mailing Address - Fax:606-487-0279
Practice Address - Street 1:120 DANIEL BOONE PLZ
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-5335
Practice Address - Country:US
Practice Address - Phone:606-487-0244
Practice Address - Fax:606-487-0279
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY275909156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician