Healthcare Provider Details

I. General information

NPI: 1104992965
Provider Name (Legal Business Name): JEAN BRIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2006
Last Update Date: 06/15/2022
Certification Date: 06/09/2022
Deactivation Date: 03/13/2014
Reactivation Date: 06/21/2018

III. Provider practice location address

6368 APPALACHIAN HIGHWAY
DAVIS WV
26260
US

IV. Provider business mailing address

8591 HOLLY MEADOWS RD
PARSONS WV
26287-8604
US

V. Phone/Fax

Practice location:
  • Phone: 304-478-3339
  • Fax:
Mailing address:
  • Phone: 304-478-3339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number67358
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: