Healthcare Provider Details

I. General information

NPI: 1699630392
Provider Name (Legal Business Name): SALLY JACOB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

212 GILCHRIST AVE
TORNADO WV
25202-9632
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-4168
  • Fax:
Mailing address:
  • Phone: 304-419-6069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number91602
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: