Healthcare Provider Details

I. General information

NPI: 1336885862
Provider Name (Legal Business Name): JEREMY COCHRAN LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 1/2 MAIN ST STE F
PT PLEASANT WV
25550-1121
US

IV. Provider business mailing address

610 1/2 MAIN ST STE F
PT PLEASANT WV
25550-1121
US

V. Phone/Fax

Practice location:
  • Phone: 304-812-5426
  • Fax:
Mailing address:
  • Phone: 304-812-5426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00947526
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: