Provider Demographics
NPI:1063957405
Name:CARPENTER, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CARPENTER
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 1:210 ANTHONI AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6403
Mailing Address - Country:US
Mailing Address - Phone:304-242-6722
Mailing Address - Fax:
Practice Address - Street 1:210 ANTHONI AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6403
Practice Address - Country:US
Practice Address - Phone:304-242-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide