Provider Demographics
NPI:1497884977
Name:STARK, JANE S (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:S
Last Name:STARK
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 E 68TH ST
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4915
Mailing Address - Country:US
Mailing Address - Phone:212-879-0671
Mailing Address - Fax:
Practice Address - Street 1:9 E 68TH ST
Practice Address - Street 2:SUITE 6A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4915
Practice Address - Country:US
Practice Address - Phone:212-879-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11136101YA0400X
NYR049784-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN535P1Medicare ID - Type Unspecified