Provider Demographics
NPI:1023222197
Name:STINES, JACKIE R JR (MD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:R
Last Name:STINES
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DRIVE
Mailing Address - Street 2:STE 3500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:304-691-1300
Mailing Address - Fax:304-691-1375
Practice Address - Street 1:1600 MEDICAL CENTER DRIVE
Practice Address - Street 2:STE 3500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-691-1300
Practice Address - Fax:304-691-1375
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV24389208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics