Provider Demographics
NPI:1679839799
Name:STARK, JEFFREY D (BA, MDIV)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:STARK
Suffix:
Gender:M
Credentials:BA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3449
Mailing Address - Country:US
Mailing Address - Phone:302-478-3848
Mailing Address - Fax:215-836-4929
Practice Address - Street 1:1006 WILSON RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3449
Practice Address - Country:US
Practice Address - Phone:302-478-3848
Practice Address - Fax:215-836-4929
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral