Provider Demographics
NPI:1881632677
Name:STUMP, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:STUMP
Suffix:
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:FILE 742997
Mailing Address - Street 2:PO BOX 60000
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2997
Mailing Address - Country:US
Mailing Address - Phone:360-514-2142
Mailing Address - Fax:360-514-6820
Practice Address - Street 1:600 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3225
Practice Address - Country:US
Practice Address - Phone:360-514-2142
Practice Address - Fax:360-514-6820
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00037100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278167Medicaid
WA8239576Medicaid
WAF38687Medicare UPIN
WAG8855559Medicare PIN