Basic Information
| Provider Information | |||||||||
| NPI: | 1952769721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORNE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 590 N POPLAR FORK RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255267106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047577826 | ||||||||
| FaxNumber: | 3047578861 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 N POPLAR FORK RD | ||||||||
| Address2: | |||||||||
| City: | HURRICANE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255267106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047577826 | ||||||||
| FaxNumber: | 3047578861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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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 | 314000000X | 0002206 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.