Provider Demographics
NPI:1619006541
Name:STARK, JENNIFER L (M A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2438
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-2438
Mailing Address - Country:US
Mailing Address - Phone:209-509-5272
Mailing Address - Fax:209-826-3663
Practice Address - Street 1:1435 W I ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4546
Practice Address - Country:US
Practice Address - Phone:209-509-5272
Practice Address - Fax:209-826-3663
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist