Provider Demographics
NPI:1063177707
Name:MIDDLETON, JACINDA
Entity type:Individual
Prefix:
First Name:JACINDA
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4967 DANS RUN RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26763-7007
Mailing Address - Country:US
Mailing Address - Phone:681-589-1166
Mailing Address - Fax:
Practice Address - Street 1:4967 DANS RUN RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:WV
Practice Address - Zip Code:26763-7007
Practice Address - Country:US
Practice Address - Phone:681-589-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator