Provider Demographics
NPI:1164648036
Name:SUTTON, JEAN CULBERTSON (MDIV)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:CULBERTSON
Last Name:SUTTON
Suffix:
Gender:F
Credentials:MDIV
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 643
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545-0643
Mailing Address - Country:US
Mailing Address - Phone:304-654-4213
Mailing Address - Fax:
Practice Address - Street 1:701 MAIN ST
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1406
Practice Address - Country:US
Practice Address - Phone:304-654-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1529101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01837398OtherBLUE CROSS PIN NUMBER