Healthcare Provider Details

I. General information

NPI: 1063731107
Provider Name (Legal Business Name): JEANNIE HEALTHCARE INCORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 MADISON ST
CHARLESTON WV
25312-2417
US

IV. Provider business mailing address

1406 MADISON ST 196 WERTZ AVE.
CHARLESTON WV
25312-2417
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-2014
  • Fax:
Mailing address:
  • Phone: 304-345-2014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number99FMG
License Number StateWV

VIII. Authorized Official

Name: JEANNIE LATICIA STEWART
Title or Position: CEO/PRESIDENT
Credential:
Phone: 304-345-2014