=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275257651
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON JONAS WOLFE LSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2022
-----------------------------------------------------
Last Update Date | 09/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HOSPITAL DR STE 3
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26847-9570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-257-1015
-----------------------------------------------------
Fax | 304-257-1129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 PONDVIEW RD
-----------------------------------------------------
City | FISHER
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26818-5600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-851-7845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | AP00945052
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------