Provider Demographics
NPI:1427706951
Name:STARK, JESSICA JOLENE (CTRS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOLENE
Last Name:STARK
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3889 WALTON RD
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49649-9639
Mailing Address - Country:US
Mailing Address - Phone:906-630-0494
Mailing Address - Fax:
Practice Address - Street 1:4040 BEACON ST
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:MI
Practice Address - Zip Code:49649-9548
Practice Address - Country:US
Practice Address - Phone:231-263-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI54643225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist