Healthcare Provider Details

I. General information

NPI: 1639033608
Provider Name (Legal Business Name): JEFFREY LLOYD STOUT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 S KITTIWAKE ST
WASILLA AK
99623-9302
US

IV. Provider business mailing address

591 S KNIK GOOSE BAY RD
WASILLA AK
99654-8062
US

V. Phone/Fax

Practice location:
  • Phone: 907-313-1333
  • Fax:
Mailing address:
  • Phone: 907-313-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: