Provider Demographics
NPI:1184001604
Name:UNDERWOOD, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:UNDERWOOD
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 1:6000 MEMORIAL CHURCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501
Mailing Address - Country:US
Mailing Address - Phone:304-292-7316
Mailing Address - Fax:304-599-8917
Practice Address - Street 1:6000 MEMORIAL CHURCH DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501
Practice Address - Country:US
Practice Address - Phone:304-292-7316
Practice Address - Fax:304-599-8917
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV68234363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016843Medicaid