Basic Information
| Provider Information | |||||||||
| NPI: | 1508145517 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFRIES | ||||||||
| FirstName: | RACHELE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 GREAT TEAYS BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3042015019 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | ELEANOR | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250700503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045860001 | ||||||||
| FaxNumber: | 3045861301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2011 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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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 | 363A00000X | 2235 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1508145517 | 05 | WV | MEDICAID | 3810020849 | 05 | WV | MEDICAID |