Provider Demographics
NPI:1124623418
Name:WHITE, JENNA LYN (RESPITE AND PCS)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LYN
Last Name:WHITE
Suffix:
Gender:F
Credentials:RESPITE AND PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:304-425-9541
Mailing Address - Fax:
Practice Address - Street 1:406 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3102
Practice Address - Country:US
Practice Address - Phone:304-308-5597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant