Provider Demographics
NPI:1407117732
Name:STAGG, JILL
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:
Last Name:STAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 N CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2109
Mailing Address - Country:US
Mailing Address - Phone:631-387-1003
Mailing Address - Fax:
Practice Address - Street 1:1004 N CLINTON AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2109
Practice Address - Country:US
Practice Address - Phone:631-387-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY781925103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst