Healthcare Provider Details

I. General information

NPI: 1093624876
Provider Name (Legal Business Name): JONATHON LOREN OBRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 VIRGINIA ST E STE 400
CHARLESTON WV
25301-2835
US

IV. Provider business mailing address

280 COMPRESSOR STATION RD
BRUCETON MILLS WV
26525-9420
US

V. Phone/Fax

Practice location:
  • Phone: 681-313-4759
  • Fax: 844-800-3954
Mailing address:
  • Phone: 219-254-0868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number126582
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: