Provider Demographics
NPI:1699778472
Name:LEAVITT, JENNIFER L (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LEAVITT
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 1:936 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-4737
Mailing Address - Country:US
Mailing Address - Phone:304-485-0272
Mailing Address - Fax:304-485-0265
Practice Address - Street 1:2900 EMERSON AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-2519
Practice Address - Country:US
Practice Address - Phone:304-485-0272
Practice Address - Fax:304-485-0265
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2125613OtherOHIO MEDICAID
WV0590002000Medicaid
WV2125613OtherOHIO MEDICAID
WV0879461Medicare PIN