Provider Demographics
NPI:1962578948
Name:JACK, STANLEY K (DO)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:K
Last Name:JACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 29TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2316
Mailing Address - Country:US
Mailing Address - Phone:303-440-8243
Mailing Address - Fax:
Practice Address - Street 1:777 29TH ST STE 301
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2316
Practice Address - Country:US
Practice Address - Phone:303-440-8243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine