Provider Demographics
NPI:1205601630
Name:STANLEY, JACOB (MSA AA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MSA AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3697 S NEW TOWN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-8136
Mailing Address - Country:US
Mailing Address - Phone:620-899-1695
Mailing Address - Fax:
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:800-392-0936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant