Provider Demographics
NPI:1336464759
Name:STAHL, JESSICA LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:STAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:81 N MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1125
Practice Address - Country:US
Practice Address - Phone:801-213-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.MD.607303252080P0210X, 2084P0804X
NC2020-032712080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry