Healthcare Provider Details

I. General information

NPI: 1467078626
Provider Name (Legal Business Name): JERRALD WAYNE BARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 INDUSTRIAL PARK RD STE 1
MAXWELTON WV
24957-8066
US

IV. Provider business mailing address

PO BOX 129
MAXWELTON WV
24957-0129
US

V. Phone/Fax

Practice location:
  • Phone: 304-497-0500
  • Fax: 304-497-2707
Mailing address:
  • Phone: 304-497-0500
  • Fax: 304-497-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: