Healthcare Provider Details

I. General information

NPI: 1295627800
Provider Name (Legal Business Name): JACQUELIN SUE SNIDER ADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARKET PL
BRIDGEPORT WV
26330-9168
US

IV. Provider business mailing address

100 MARKET PL
BRIDGEPORT WV
26330-9168
US

V. Phone/Fax

Practice location:
  • Phone: 304-848-5770
  • Fax:
Mailing address:
  • Phone: 304-848-5770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15-114
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: