Provider Demographics
NPI:1144487703
Name:STAHL, JESSICA AWINITA (PSYD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AWINITA
Last Name:STAHL
Suffix:
Gender:F
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:PO BOX 2008
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-1941
Mailing Address - Country:US
Mailing Address - Phone:530-210-6202
Mailing Address - Fax:
Practice Address - Street 1:408 BROAD ST
Practice Address - Street 2:STE 10B
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2455
Practice Address - Country:US
Practice Address - Phone:530-210-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24773103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist