| Doctor Name: | JAXSON LAYNE STARK |
| NPI Number: | 1144559527 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | B.A. |
| License Number: | |
| Business Practice Address: | 1441 Falcon Dr Apt 1 Ammon, ID - 834065840 |
| Business Phone Number: | 2083600067 |
| Business Fax Number: | |
| Mailing Address: | 1441 Falcon Dr Apt 1, AMMON |
| State: | ID |
| Postal Code: | 834065840 |
| Phone Number: | 2083600067 |
| Fax Number: | |
| NPI Enumeration Date: | 12/15/2009 |
| NPI Last Update Date: | 12/15/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2255R0406X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Specialist/Technologist |
| Taxonomy Specialization: | Rehabilitation, Blind |
| Taxonomy Definition: | |