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NPI Code Detail

MEDICARE: J. THOMAS STACK, PH.D., PA

MEDICARE: J. THOMAS STACK, PH.D., PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)0321NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
20320667OTHERNCBLUE CROSS
38D26D8F5BEOTHERTRICARE

General Provider Information

NPI Number : 1962519165
Entity Type Code : Organization
Provider Name (Legal Business Name) : J. THOMAS STACK, PH.D., PA
Provider Business Mailing Address
First Line : 2444 COMMERCE RD
Second Line :
City : JACKSONVILLE
State : NC
Zip : 28546-7560
Country : US
Telephone Number : 910-347-5511
Fax Number : 910-346-3970
Provider Business Practice Location Address
First Line : 2444 COMMERCE RD
Second Line :
City : JACKSONVILLE
State : NC
Zip : 28546-7560
Country : US
Telephone Number : 910-347-5511
Fax Number : 910-346-3970
Authorized Official
Title or Position : PRESIDENT
Name : DR. J THOMAS STACK
Credential : PH.D.
Telephone Number : 910-347-5511
Provider Enumeration Date : 08/24/2006
Last Update Date : 08/22/2020

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