Healthcare Provider Details

I. General information

NPI: 1689406563
Provider Name (Legal Business Name): JACOB S QUEEN PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DONOHOE DR
HUNTINGTON WV
25705-8887
US

IV. Provider business mailing address

55 DONOHOE DR
HUNTINGTON WV
25705-8887
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-7851
  • Fax: 304-525-1073
Mailing address:
  • Phone: 304-525-7851
  • Fax: 304-525-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number24-9103
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: