Provider Demographics
NPI:1194886846
Name:STARK, JEANNE L (LMSW)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 PARKWAY PL SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2695
Mailing Address - Country:US
Mailing Address - Phone:616-530-9011
Mailing Address - Fax:616-530-9011
Practice Address - Street 1:3351 CLAYSTONE ST SE
Practice Address - Street 2:STE. 212
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5781
Practice Address - Country:US
Practice Address - Phone:616-954-1992
Practice Address - Fax:616-954-1998
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088180104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker