Provider Demographics
NPI:1376822999
Name:JABLON, STACIE F (MFT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:F
Last Name:JABLON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 GRIFFIN CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-6100
Mailing Address - Country:US
Mailing Address - Phone:951-496-4633
Mailing Address - Fax:
Practice Address - Street 1:2909 GRIFFIN CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-6100
Practice Address - Country:US
Practice Address - Phone:951-496-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-13
Last Update Date:2011-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36550106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist