Provider Demographics
NPI:1831923754
Name:STARK, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:STARK
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 1:1630 N HUMBOLDT BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5016
Mailing Address - Country:US
Mailing Address - Phone:773-721-7668
Mailing Address - Fax:
Practice Address - Street 1:1630 N HUMBOLDT BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5016
Practice Address - Country:US
Practice Address - Phone:773-721-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist