Provider Demographics
NPI:1710692819
Name:STACKHOUSE, JONATHON
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:
Last Name:STACKHOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 NW HWY W
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64061
Mailing Address - Country:US
Mailing Address - Phone:816-308-0246
Mailing Address - Fax:816-566-0486
Practice Address - Street 1:1525 N 7 HWY STE 201
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:MO
Practice Address - Zip Code:64080-1980
Practice Address - Country:US
Practice Address - Phone:816-308-0246
Practice Address - Fax:816-566-0486
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021002313101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor