Provider Demographics
NPI:1063731107
Name:JEANNIE HEALTHCARE INCORPORATION
Entity type:Organization
Organization Name:JEANNIE HEALTHCARE INCORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:LATICIA
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-345-2014
Mailing Address - Street 1:1406 MADISON ST
Mailing Address - Street 2:196 WERTZ AVE.
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-2417
Mailing Address - Country:US
Mailing Address - Phone:304-345-2014
Mailing Address - Fax:
Practice Address - Street 1:1406 MADISON ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-2417
Practice Address - Country:US
Practice Address - Phone:304-345-2014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV99FMG302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization