Provider Demographics
NPI:1316309248
Name:HEDRICK, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HEDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:HEDRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:MOUNT NEBO
Mailing Address - State:WV
Mailing Address - Zip Code:26679-0201
Mailing Address - Country:US
Mailing Address - Phone:304-228-1012
Mailing Address - Fax:
Practice Address - Street 1:1 AMES HEIGHTS ROAD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:WV
Practice Address - Zip Code:25862-0078
Practice Address - Country:US
Practice Address - Phone:304-228-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2002-0874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist