Provider Demographics
NPI:1275720260
Name:STARK, JENNIFER DAWN (MSW, LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DAWN
Last Name:STARK
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WV
Mailing Address - Zip Code:26814-0021
Mailing Address - Country:US
Mailing Address - Phone:304-567-3167
Mailing Address - Fax:
Practice Address - Street 1:15 GRANT ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1687
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCP009393581041C0700X
WVDP009393581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical