Provider Demographics
NPI:1578848222
Name:STAGG, JESSILYN
Entity Type:Individual
Prefix:
First Name:JESSILYN
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 1:6275 BOULDER HWY APT 2104
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-7702
Mailing Address - Country:US
Mailing Address - Phone:435-632-9627
Mailing Address - Fax:
Practice Address - Street 1:6275 BOULDER HWY APT 2104
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-7702
Practice Address - Country:US
Practice Address - Phone:435-632-9627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner