Provider Demographics
NPI:1598800856
Name:JURGENS, STACY LEE
Entity Type:Individual
Prefix:MISS
First Name:STACY
Middle Name:LEE
Last Name:JURGENS
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 1:5210 TERNER WAY APT 239
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-4162
Mailing Address - Country:US
Mailing Address - Phone:408-930-4938
Mailing Address - Fax:
Practice Address - Street 1:455 SILICON VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138-1858
Practice Address - Country:US
Practice Address - Phone:408-284-9084
Practice Address - Fax:408-284-9073
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50139106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist