Provider Demographics
NPI:1831239847
Name:JACOBS, STACEY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:GILLIAM
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1402 WOODLAND COURT
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861-1000
Mailing Address - Country:US
Mailing Address - Phone:830-426-1977
Mailing Address - Fax:
Practice Address - Street 1:1313 LORENZO
Practice Address - Street 2:#3
Practice Address - City:CASTROVILLE
Practice Address - State:TX
Practice Address - Zip Code:78009-4532
Practice Address - Country:US
Practice Address - Phone:830-538-2236
Practice Address - Fax:830-931-2007
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1781346Medicaid