Provider Demographics
NPI:1114495645
Name:STUMBO, JADE (DPT)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:STUMBO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 S CAROL MALONE BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1352
Mailing Address - Country:US
Mailing Address - Phone:606-474-7649
Mailing Address - Fax:606-474-0855
Practice Address - Street 1:144 S CAROL MALONE BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1352
Practice Address - Country:US
Practice Address - Phone:606-474-7649
Practice Address - Fax:606-474-0855
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist