Healthcare Provider Details

I. General information

NPI: 1962578948
Provider Name (Legal Business Name): STANLEY K JACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2995 BASELINE RD STE 200
BOULDER CO
80303-2318
US

IV. Provider business mailing address

2995 BASELINE RD STE 200
BOULDER CO
80303-2318
US

V. Phone/Fax

Practice location:
  • Phone: 303-440-8243
  • Fax:
Mailing address:
  • Phone: 303-440-8243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42877
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: