Healthcare Provider Details

I. General information

NPI: 1275444838
Provider Name (Legal Business Name): MARISSA JARVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PARK DRIVE
MASONTOWN WV
26542
US

IV. Provider business mailing address

PO BOX 66
MASONTOWN WV
26542-0066
US

V. Phone/Fax

Practice location:
  • Phone: 304-278-4005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: