Provider Demographics
NPI:1770746539
Name:NIJST, STACEY MAX (CADCA, CCJP)
Entity type:Individual
Prefix:MR
First Name:STACEY
Middle Name:MAX
Last Name:NIJST
Suffix:
Gender:M
Credentials:CADCA, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 N BROADWAY STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2663
Mailing Address - Country:US
Mailing Address - Phone:714-221-6400
Mailing Address - Fax:
Practice Address - Street 1:2215 N BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2663
Practice Address - Country:US
Practice Address - Phone:714-221-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist