Healthcare Provider Details

I. General information

NPI: 1164003471
Provider Name (Legal Business Name): JESSICA FANCHER COLE DSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W LIBERTY ST STE 202
CHARLES TOWN WV
25414-1548
US

IV. Provider business mailing address

PO BOX 3314
SHEPHERDSTOWN WV
25443-3314
US

V. Phone/Fax

Practice location:
  • Phone: 304-629-0900
  • Fax:
Mailing address:
  • Phone: 304-629-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00944444
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: