Provider Demographics
NPI:1417117391
Name:STIRGWOLT, JENNIFER K (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:STIRGWOLT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:RIVERSIDE MEDICAL GROUP
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:
Practice Address - Street 1:4917 RICHMOND TAPPAHANNOCK HWY STE 1B
Practice Address - Street 2:KING WILLIAM MEDICAL CENTER
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3416
Practice Address - Country:US
Practice Address - Phone:804-769-1245
Practice Address - Fax:804-769-1342
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204513207Q00000X
NEPA-OS015678-A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARES0000Medicare UPIN