Healthcare Provider Details

I. General information

NPI: 1013618065
Provider Name (Legal Business Name): MICHAEL BRYAN STACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LAKELAND DR
JACKSON MS
39216-4829
US

IV. Provider business mailing address

1606 LAUREL ST
JACKSON MS
39202-1243
US

V. Phone/Fax

Practice location:
  • Phone: 769-777-1000
  • Fax:
Mailing address:
  • Phone: 601-942-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85361
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-226002
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: