Provider Demographics
NPI:1700147477
Name:STUMP, JACQUELINE HOWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:HOWARD
Last Name:STUMP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 VIRGINIA ST E STE 1
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3053
Mailing Address - Country:US
Mailing Address - Phone:304-343-8805
Mailing Address - Fax:304-343-8806
Practice Address - Street 1:1321 VIRGINIA ST E STE 1
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3053
Practice Address - Country:US
Practice Address - Phone:304-343-8805
Practice Address - Fax:304-343-8806
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice