Provider Demographics
NPI:1427525005
Name:WEAVER, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:SIZEMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:318 WELCHBURG ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:ANNVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40402-9661
Mailing Address - Country:US
Mailing Address - Phone:606-493-7340
Mailing Address - Fax:
Practice Address - Street 1:86 HIGHWAY 638 STE 1
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7289
Practice Address - Country:US
Practice Address - Phone:606-598-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY245738OtherLICENSE NUMBER