Provider Demographics
NPI:1790402535
Name:STAKOFSKY, JESSICA SHANNA (FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHANNA
Last Name:STAKOFSKY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SLOOP SQ
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-3755
Mailing Address - Country:US
Mailing Address - Phone:908-692-6766
Mailing Address - Fax:
Practice Address - Street 1:19 SLOOP SQ
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-3755
Practice Address - Country:US
Practice Address - Phone:908-692-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ26NJ01392500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program