Provider Demographics
NPI:1508135955
Name:STAMPER, MARY JENNIFER (ICADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JENNIFER
Last Name:STAMPER
Suffix:
Gender:F
Credentials:ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 LILAC CT
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-9292
Mailing Address - Country:US
Mailing Address - Phone:859-333-0419
Mailing Address - Fax:
Practice Address - Street 1:1589 HILL RISE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2588
Practice Address - Country:US
Practice Address - Phone:859-977-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)