Provider Demographics
NPI:1851473466
Name:JACKSON, STACY L (DC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 MT DIABLO CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4084
Mailing Address - Country:US
Mailing Address - Phone:925-952-4222
Mailing Address - Fax:925-952-4212
Practice Address - Street 1:3249 MT DIABLO CT
Practice Address - Street 2:SUITE 102
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4084
Practice Address - Country:US
Practice Address - Phone:925-952-4222
Practice Address - Fax:925-952-4212
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0194550OtherPTAN