Basic Information
| Provider Information | |||||||||
| NPI: | 1144434424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STUMBO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | STE. 290 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022178221 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 CENTRAL AVE | ||||||||
| Address2: | STE. 110 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402081449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525205 | ||||||||
| FaxNumber: | 5028525405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39532 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 39532 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RS0010X | 39532 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200910080 | 05 | IN | MEDICAID | 7100061440 | 05 | KY | MEDICAID |