Healthcare Provider Details

I. General information

NPI: 1265383269
Provider Name (Legal Business Name): SARAH ELAINE JACK AS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GREYHOUND LANE
SMITHERS WV
25186
US

IV. Provider business mailing address

14 E GRAFTON RD STE C
FAIRMONT WV
26554-4465
US

V. Phone/Fax

Practice location:
  • Phone: 681-549-9256
  • Fax:
Mailing address:
  • Phone: 681-549-9256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: