Healthcare Provider Details

I. General information

NPI: 1629669171
Provider Name (Legal Business Name): MRS. JACQUELINE ANN O'NEIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 WEST BIRCH LANE
ROMMEY WV
26757
US

IV. Provider business mailing address

285 WEST BIRCH LANE
ROMMEY WV
26757
US

V. Phone/Fax

Practice location:
  • Phone: 304-359-2380
  • Fax: 304-359-2393
Mailing address:
  • Phone: 304-359-2380
  • Fax: 304-359-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number458
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number458
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: