Basic Information
| Provider Information | |||||||||
| NPI: | 1245369743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRIMBLE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3761 TEAYS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047601180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3761 TEAYS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255269705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047601180 | ||||||||
| FaxNumber: | 3047601189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2610 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 2610 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 3810008749 | 05 | WV | MEDICAID |