Provider Demographics
NPI:1215533864
Name:STEPHENS, JARRED MICHAEL
Entity Type:Individual
Prefix:
First Name:JARRED
Middle Name:MICHAEL
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 PLEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-5208
Mailing Address - Country:US
Mailing Address - Phone:304-840-4496
Mailing Address - Fax:
Practice Address - Street 1:4329 HUGHES BRANCH RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-9768
Practice Address - Country:US
Practice Address - Phone:304-733-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant