Healthcare Provider Details

I. General information

NPI: 1174888341
Provider Name (Legal Business Name): JESSICA STARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 FANNIN ST STE 2150
HOUSTON TX
77030-1524
US

IV. Provider business mailing address

6400 FANNIN ST STE 2070
HOUSTON TX
77030-1541
US

V. Phone/Fax

Practice location:
  • Phone: 713-486-8100
  • Fax: 713-486-8101
Mailing address:
  • Phone: 713-486-7747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberS0802
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: