Provider Demographics
NPI:1932965936
Name:STANLEY, JACOB SCOTT
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SCOTT
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 SHOALS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-8515
Mailing Address - Country:US
Mailing Address - Phone:304-638-9834
Mailing Address - Fax:
Practice Address - Street 1:135 4TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1219
Practice Address - Country:US
Practice Address - Phone:855-978-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program