Healthcare Provider Details

I. General information

NPI: 1780520643
Provider Name (Legal Business Name): JACOB TALLAMY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 SKIDMORE LN
SUTTON WV
26601-9271
US

IV. Provider business mailing address

266 SKIDMORE LN
SUTTON WV
26601-9271
US

V. Phone/Fax

Practice location:
  • Phone: 304-765-4400
  • Fax: 844-351-9630
Mailing address:
  • Phone: 304-765-4400
  • Fax: 844-351-9630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: