Provider Demographics
NPI:1891027231
Name:STAHL, JEREMY I
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:I
Last Name:STAHL
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 1:132 PRYCE ST
Mailing Address - Street 2:APT A
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2838
Mailing Address - Country:US
Mailing Address - Phone:650-533-2402
Mailing Address - Fax:
Practice Address - Street 1:102 WHEELOCK RD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-9719
Practice Address - Country:US
Practice Address - Phone:831-768-0941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health