Provider Demographics
NPI:1962519165
Name:J. THOMAS STACK, PH.D., PA
Entity type:Organization
Organization Name:J. THOMAS STACK, PH.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-347-5511
Mailing Address - Street 1:2444 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7560
Mailing Address - Country:US
Mailing Address - Phone:910-347-5511
Mailing Address - Fax:910-346-3970
Practice Address - Street 1:2444 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7560
Practice Address - Country:US
Practice Address - Phone:910-347-5511
Practice Address - Fax:910-346-3970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0321261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000016Medicaid
NC0320667OtherBLUE CROSS
8D26D8F5BEOtherTRICARE