Provider Demographics
NPI:1992442537
Name:STARK, JAYLENE O (LMHCA)
Entity type:Individual
Prefix:
First Name:JAYLENE
Middle Name:O
Last Name:STARK
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N 50TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-2800
Mailing Address - Country:US
Mailing Address - Phone:509-949-3616
Mailing Address - Fax:
Practice Address - Street 1:120 N 50TH AVE STE B
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-2800
Practice Address - Country:US
Practice Address - Phone:509-574-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61027049101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health