Healthcare Provider Details

I. General information

NPI: 1811469638
Provider Name (Legal Business Name): JACI R GUMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 BLACKJACK RD
MOUNT VERNON OH
43050-9193
US

IV. Provider business mailing address

8402 BLACKJACK RD
MOUNT VERNON OH
43050-9193
US

V. Phone/Fax

Practice location:
  • Phone: 740-485-9887
  • Fax:
Mailing address:
  • Phone: 740-485-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1811469638
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.173829
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: