Provider Demographics
NPI:1679003594
Name:STINE, JEFFREY R (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:STINE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 14TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7340
Mailing Address - Country:US
Mailing Address - Phone:701-404-0997
Mailing Address - Fax:701-566-8876
Practice Address - Street 1:6046 14TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7340
Practice Address - Country:US
Practice Address - Phone:701-404-0997
Practice Address - Fax:701-566-8876
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND51091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical