Healthcare Provider Details

I. General information

NPI: 1801061932
Provider Name (Legal Business Name): BERKELEY COUNTY FOOT AND ANKLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 HEDGESVILLE ROAD SUITE O
HEDGESVILLE WV
25427-6704
US

IV. Provider business mailing address

3790 HEDGESVILLE RD SUITE O
HEDGESVILLE WV
25427-6704
US

V. Phone/Fax

Practice location:
  • Phone: 304-754-7130
  • Fax: 717-762-1831
Mailing address:
  • Phone: 304-754-7130
  • Fax: 717-762-1831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number10391
License Number StateWV

VIII. Authorized Official

Name: DR. JOHN S JACKO
Title or Position: OWNER
Credential: D.P.M.
Phone: 304-754-7130