Provider Demographics
NPI:1144559527
Name:STARK, JAXSON LAYNE (MS)
Entity type:Individual
Prefix:
First Name:JAXSON
Middle Name:LAYNE
Last Name:STARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 N HADERLIE LN
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-7723
Mailing Address - Country:US
Mailing Address - Phone:208-360-0067
Mailing Address - Fax:
Practice Address - Street 1:2705 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6601
Practice Address - Country:US
Practice Address - Phone:208-360-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 5501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health