Provider Demographics
NPI:1164172623
Name:CROSS, JATEIYA
Entity Type:Individual
Prefix:
First Name:JATEIYA
Middle Name:
Last Name:CROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 PHILPOTT LN
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-9501
Mailing Address - Country:US
Mailing Address - Phone:304-254-9262
Mailing Address - Fax:
Practice Address - Street 1:175 PHILPOTT LN
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-9501
Practice Address - Country:US
Practice Address - Phone:304-254-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVY8Z4D8E7OtherMA