Individual
JAXSON LAYNE STARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MS
Contact information
Practice address
2705 E 17TH ST, AMMON, ID 83406-6601
(208) 360-0067
Mailing address
3770 N HADERLIE LN, IONA, ID 83427-7723
(208) 360-0067
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LCPC 5501
ID
Other
Enumeration date
12/15/2009
Last updated
12/06/2023
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