Basic Information
| Provider Information | |||||||||
| NPI: | 1568865061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 SALT LAKE BLVD STE D8 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968183172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085916060 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4510 SALT LAKE BLVD STE D8 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968183172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085916060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-14-5813 | HI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.