Provider Demographics
NPI:1639389372
Name:MYERS, JEANNETTE STARK (BCABA)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:STARK
Last Name:MYERS
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SCOTT HILL DR
Mailing Address - Street 2:
Mailing Address - City:ORCAS
Mailing Address - State:WA
Mailing Address - Zip Code:98280-0399
Mailing Address - Country:US
Mailing Address - Phone:360-376-3744
Mailing Address - Fax:360-376-3744
Practice Address - Street 1:85 SCOTT HILL DR
Practice Address - Street 2:
Practice Address - City:ORCAS
Practice Address - State:WA
Practice Address - Zip Code:98280-0399
Practice Address - Country:US
Practice Address - Phone:360-376-3744
Practice Address - Fax:360-376-3744
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-03-0894103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities