Provider Demographics
NPI:1043183957
Name:TOLLIVER, JEROME VALENTINO
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:VALENTINO
Last Name:TOLLIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 LORETTA LN
Mailing Address - Street 2:
Mailing Address - City:S CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-8411
Mailing Address - Country:US
Mailing Address - Phone:304-239-4411
Mailing Address - Fax:
Practice Address - Street 1:847 LORETTA LN
Practice Address - Street 2:
Practice Address - City:S CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8411
Practice Address - Country:US
Practice Address - Phone:304-239-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant