Healthcare Provider Details

I. General information

NPI: 1205883477
Provider Name (Legal Business Name): JESSICA FAE WOY GOULD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA FAE WOY PA-C

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 3 BOX 3267
KEYSER WV
26726-9422
US

IV. Provider business mailing address

PO BOX 944
KEYSER WV
26726-0944
US

V. Phone/Fax

Practice location:
  • Phone: 304-788-6462
  • Fax: 304-788-6555
Mailing address:
  • Phone: 304-788-6462
  • Fax: 304-788-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01035
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: