Individual ProviderJacob David StarkCounselorBehavioral Health & Social Service ProvidersPractice Address10373 NE Hancock St Ste 200, Portland, OR 97220-3873(503) 253-6754(503) 238-0769PECOS EnrollmentBased on the most recent information from CMS, provider Jacob David Stark does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1225863897Provider TypeIndividualFull NameStark, Jacob DavidGenderMaleSole ProprietorNoEnumeration Date9/4/2024Last Updated9/4/2024Contact InformationPractice LocationPractice Address10373 NE Hancock St Ste 200, Portland, OR 97220-3873Phone(503) 253-6754FaxUnlisted FaxMailing LocationMailing AddressPO Box 8459, Portland, OR 97207-8459Phone(503) 238-0769FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode101YM0800XPrimaryDescriptionCounselorBehavioral Health & Social Service ProvidersLicenseUnlisted Issuer