Provider Demographics
NPI:1053518738
Name:STOVALL, JON (MA, MFT)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:STOVALL
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 E PALMDALE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-2034
Mailing Address - Country:US
Mailing Address - Phone:661-949-0131
Mailing Address - Fax:
Practice Address - Street 1:921 W AVENUE J
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC14975106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist