Provider Demographics
NPI:1275769275
Name:BEVERAGE, JENNIFER E (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BEVERAGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26280-0247
Mailing Address - Country:US
Mailing Address - Phone:304-335-2050
Mailing Address - Fax:
Practice Address - Street 1:46 TOWN CENTER PLZ STE A
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WV
Practice Address - Zip Code:26280-9752
Practice Address - Country:US
Practice Address - Phone:304-335-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206565207Q00000X
WV2462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2034423Medicare PIN
WV2034421Medicare PIN
WV2034427Medicare PIN
WV2034425Medicare PIN
WV2034422Medicare PIN
WV2034426Medicare PIN
WV2034424Medicare PIN