Provider Demographics
NPI:1598051070
Name:STAHLE, JESSICA TANDY
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:TANDY
Last Name:STAHLE
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 1:480 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2323
Mailing Address - Country:US
Mailing Address - Phone:801-831-0630
Mailing Address - Fax:801-797-9412
Practice Address - Street 1:480 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-2323
Practice Address - Country:US
Practice Address - Phone:801-831-0630
Practice Address - Fax:801-797-9412
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay