Provider Demographics
NPI:1942497656
Name:STACKHOUSE, NATHAN JON
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:JON
Last Name:STACKHOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 HANCOCK RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5946
Mailing Address - Country:US
Mailing Address - Phone:567-224-8821
Mailing Address - Fax:
Practice Address - Street 1:2380 3RD ST
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86429-5502
Practice Address - Country:US
Practice Address - Phone:567-224-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3941434101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool