Healthcare Provider Details

I. General information

NPI: 1063957405
Provider Name (Legal Business Name): JACOB CARPENTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 ANTHONI AVE
WHEELING WV
26003-6403
US

IV. Provider business mailing address

210 ANTHONI AVE
WHEELING WV
26003-6403
US

V. Phone/Fax

Practice location:
  • Phone: 304-242-6722
  • Fax:
Mailing address:
  • Phone: 304-242-6722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: