Basic Information
| Provider Information | |||||||||
| NPI: | 1407944234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFREY | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 TRACY WAY | ||||||||
| Address2: | STE 2 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 TRACY WAY | ||||||||
| Address2: | STE 2 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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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 | 208000000X | WV18284 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0110363000 | 05 | WV | MEDICAID | WV18284 | 01 | WV | WV LICENSE NUMBER | OTHER | 011036300 | 05 | WV | MEDICAID |