Provider Demographics
NPI:1588167100
Name:DEJONG BARNES, STACY JO
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:DEJONG BARNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 2ND ST SW STE E
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-4127
Mailing Address - Country:US
Mailing Address - Phone:507-884-2041
Mailing Address - Fax:
Practice Address - Street 1:1812 2ND ST SW STE E
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4127
Practice Address - Country:US
Practice Address - Phone:507-884-2041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46854225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist