Healthcare Provider Details

I. General information

NPI: 1144939042
Provider Name (Legal Business Name): JESSICA MARIE MAYNARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number34040
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: