MEDICARE: JACKIE L COLEMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1255124558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE L COLEMAN

Provider Business Mailing Address
First Line	:	1586 1/2 WASHINGTON ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2509
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1586 1/2 WASHINGTON ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2509
Country	:	US
Telephone Number	:	304-419-3930
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2025
Last Update Date	:	05/28/2025

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Directions to “ JACKIE L COLEMAN ” Practice Location

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