Provider Demographics
NPI:1194045435
Name:STEWART, JEANNIE LATICIA
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:LATICIA
Last Name:STEWART
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 1:196 WERTZ AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1726
Mailing Address - Country:US
Mailing Address - Phone:304-345-2014
Mailing Address - Fax:
Practice Address - Street 1:196 WERTZ AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1726
Practice Address - Country:US
Practice Address - Phone:304-345-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV99FMG172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker