Healthcare Provider Details

I. General information

NPI: 1215922174
Provider Name (Legal Business Name): REBECCA V ST JEAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1510
US

IV. Provider business mailing address

4030 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1510
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-2220
  • Fax: 304-766-0824
Mailing address:
  • Phone: 304-766-2220
  • Fax: 304-766-0824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number989OD
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: