Healthcare Provider Details

I. General information

NPI: 1770025850
Provider Name (Legal Business Name): JESSICA R WOLFE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3554 TEAYS VALLEY RD SUITE 102
HURRICANE WV
25526-9169
US

IV. Provider business mailing address

PO BOX 4100
BARBOURSVILLE WV
25504-4100
US

V. Phone/Fax

Practice location:
  • Phone: 304-397-6909
  • Fax: 866-332-2962
Mailing address:
  • Phone: 304-397-6909
  • Fax: 866-332-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23611
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: