Provider Demographics
NPI:1528655321
Name:STAHL, JASON ANDREW (PSYD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:STAHL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 E GUSTAFSON RD
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-8317
Mailing Address - Country:US
Mailing Address - Phone:218-235-1378
Mailing Address - Fax:
Practice Address - Street 1:332 W SUPERIOR ST STE 300
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1844
Practice Address - Country:US
Practice Address - Phone:218-722-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2681101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional