Provider Demographics
NPI:1023619665
Name:STONE, JACKSON LEE
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:LEE
Last Name:STONE
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 1:2525 WEWATTA WAY APT 260
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80216-3753
Mailing Address - Country:US
Mailing Address - Phone:913-220-8270
Mailing Address - Fax:
Practice Address - Street 1:3800 W 44TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-1305
Practice Address - Country:US
Practice Address - Phone:303-458-8418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0023372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist