Provider Demographics
NPI:1285051474
Name:STARK, JEAN M (MS, NCC, LPCI)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:STARK
Suffix:
Gender:F
Credentials:MS, NCC, LPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1381
Mailing Address - Street 2:69705 LAKE DRIVE
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-1381
Mailing Address - Country:US
Mailing Address - Phone:541-815-4793
Mailing Address - Fax:
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3248101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor