=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013629617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN MERCEDES STEGEL RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2022
-----------------------------------------------------
Last Update Date | 12/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1540 SPRING VALLEY DR
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25704-9501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-429-6755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 52 ROBIN HOOD LN
-----------------------------------------------------
City | MOUNT HOPE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25880-9557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-575-9177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 1170
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------