Healthcare Provider Details

I. General information

NPI: 1760433254
Provider Name (Legal Business Name): JAYNE LADIER CANTERBURY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2869 SENECA TRL S
PETERSTOWN WV
24963-5037
US

IV. Provider business mailing address

PO BOX 590
UNION WV
24983-0590
US

V. Phone/Fax

Practice location:
  • Phone: 304-753-4336
  • Fax: 304-772-5553
Mailing address:
  • Phone: 304-772-5555
  • Fax: 304-772-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1562
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: