Provider Demographics
NPI:1881611390
Name:JACOBS, STACEY LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYNN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 FAREWELL ST
Mailing Address - Street 2:APT 2
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2564
Mailing Address - Country:US
Mailing Address - Phone:401-845-0564
Mailing Address - Fax:401-847-4245
Practice Address - Street 1:19 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2937
Practice Address - Country:US
Practice Address - Phone:401-845-0564
Practice Address - Fax:401-847-4245
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN029371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1223G0001XOtherTAXONOMY NUMBER
RI1881611390OtherNPI NUMBER
RIJS61781Medicaid