Healthcare Provider Details

I. General information

NPI: 1962336545
Provider Name (Legal Business Name): JILL RENAE SELLS PRSS-MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

IV. Provider business mailing address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-9541
  • Fax: 304-425-1332
Mailing address:
  • Phone: 304-425-9541
  • Fax: 304-425-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number26-921MH
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: