Basic Information
| Provider Information | |||||||||
| NPI: | 1013920347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 99C | ||||||||
| Address2: | |||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261649703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043722749 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 PINNELL STREET | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043722731 | ||||||||
| FaxNumber: | 3043722749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 58536 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3810006265 | 05 | WV | MEDICAID | 9328803 | 01 | WV | GROUP PTAN | OTHER | WV0245A | 01 | WV | PTAN | OTHER |