Basic Information
| Provider Information | |||||||||
| NPI: | 1881632677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STUMP | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 742997 | ||||||||
| Address2: | PO BOX 60000 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900742997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605142142 | ||||||||
| FaxNumber: | 3605146820 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 NE 92ND AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986643225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605142142 | ||||||||
| FaxNumber: | 3605146820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00037100 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 278167 | 05 | OR | MEDICAID | 8239576 | 05 | WA | MEDICAID |