Provider Demographics
NPI:1215016118
Name:MALLOW, JENNIFER A (FNP-BC)
Entity type:Individual
Prefix:PROF
First Name:JENNIFER
Middle Name:A
Last Name:MALLOW
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:VESHNESKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 9620
Mailing Address - Street 2:6613 HEALTH SCIENCES SOUTH
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9620
Mailing Address - Country:US
Mailing Address - Phone:304-293-1402
Mailing Address - Fax:
Practice Address - Street 1:SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV56084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1475OtherWV RX #