Provider Demographics
NPI:1144434424
Name:STUMBO, JESSICA RUTH (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RUTH
Last Name:STUMBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1230 MARKET ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-7986
Practice Address - Country:US
Practice Address - Phone:502-225-6900
Practice Address - Fax:502-666-7693
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39532207RS0010X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100061440Medicaid
IN200910080Medicaid
KY7100061440Medicaid
KY0523976Medicare PIN
KY0048471Medicare PIN