Provider Demographics
NPI:1063230324
Name:VANCE, JENNIFER ROSE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:VANCE
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 1:127 MOUNTAIN TRL
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:WV
Mailing Address - Zip Code:25984-8710
Mailing Address - Country:US
Mailing Address - Phone:681-489-5502
Mailing Address - Fax:
Practice Address - Street 1:127 MOUNTAIN TRL
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:WV
Practice Address - Zip Code:25984-8710
Practice Address - Country:US
Practice Address - Phone:681-489-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant