Provider Demographics
NPI:1760843353
Name:STUMBAUGH, JACOB (OTR)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STUMBAUGH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MESQUITE DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78578-2708
Mailing Address - Country:US
Mailing Address - Phone:956-607-8329
Mailing Address - Fax:
Practice Address - Street 1:1200 W HIGHWAY 100
Practice Address - Street 2:SUITE 9
Practice Address - City:PORT ISABEL
Practice Address - State:TX
Practice Address - Zip Code:78578
Practice Address - Country:US
Practice Address - Phone:956-607-8329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117104225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist