Provider Demographics
NPI:1720359060
Name:STOUT, JACLYN ROSE
Entity Type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:ROSE
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-0422
Mailing Address - Country:US
Mailing Address - Phone:805-746-9501
Mailing Address - Fax:
Practice Address - Street 1:1326 JUANITA AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-0422
Practice Address - Country:US
Practice Address - Phone:805-746-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor