MEDICARE: CHARLES JACOB STOCKWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10050-M	NV
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1750914792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES JACOB STOCKWELL

Provider Business Mailing Address
First Line	:	2473 BENCH REEF PL
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-5202
Country	:	US
Telephone Number	:	702-672-8434
Fax Number	:

Provider Business Practice Location Address
First Line	:	2473 BENCH REEF PL
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-5202
Country	:	US
Telephone Number	:	702-672-8434
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2020
Last Update Date	:	06/07/2022

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Directions to “ CHARLES JACOB STOCKWELL ” Practice Location

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