Provider Demographics
NPI:1982244687
Name:STARK, JOHN GILBERT JR (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GILBERT
Last Name:STARK
Suffix:JR
Gender:M
Credentials:MA, LMHC
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:G
Other - Last Name:STARK
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MA LMHC
Mailing Address - Street 1:417 ARNOLD CT
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3702
Mailing Address - Country:US
Mailing Address - Phone:765-618-7879
Mailing Address - Fax:
Practice Address - Street 1:417 ARNOLD CT
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3702
Practice Address - Country:US
Practice Address - Phone:765-618-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001934A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health