MEDICARE: JACK CHRISTOPHER STEPHENS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	000000	WV

General Provider Information

NPI Number	:	1467163865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK CHRISTOPHER STEPHENS

Provider Business Mailing Address
First Line	:	602 13TH AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-3228
Country	:	US
Telephone Number	:	304-544-6463
Fax Number	:

Provider Business Practice Location Address
First Line	:	1236 5TH AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-2207
Country	:	US
Telephone Number	:	304-544-6463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2022
Last Update Date	:	12/07/2022

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