Healthcare Provider Details

I. General information

NPI: 1811249956
Provider Name (Legal Business Name): JENNIFER LYNN THAYER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2012
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 KOONTZ AVE STE 200
CLENDENIN WV
25045-9581
US

IV. Provider business mailing address

104 ALEX LN
CHARLESTON WV
25304-2952
US

V. Phone/Fax

Practice location:
  • Phone: 304-548-7272
  • Fax: 304-548-7149
Mailing address:
  • Phone: 304-734-2040
  • Fax: 304-734-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01691
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: