Healthcare Provider Details

I. General information

NPI: 1629445788
Provider Name (Legal Business Name): JENA CORY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 D ST
SOUTH CHARLESTON WV
25303-3104
US

IV. Provider business mailing address

218 D ST
SOUTH CHARLESTON WV
25303-3104
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-3835
  • Fax:
Mailing address:
  • Phone: 304-720-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1222
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1222
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: