Provider Demographics
NPI:1275769275
Name:BEVERAGE, JENNIFER E (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BEVERAGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 JACKSON RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:VA
Mailing Address - Zip Code:24465-2416
Mailing Address - Country:US
Mailing Address - Phone:540-468-6400
Mailing Address - Fax:404-683-3301
Practice Address - Street 1:120 JACKSON RIVER RD
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:VA
Practice Address - Zip Code:24465-2416
Practice Address - Country:US
Practice Address - Phone:540-468-6400
Practice Address - Fax:404-683-3301
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2462207Q00000X
VA0102206565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2034423Medicare PIN
WV2034421Medicare PIN
WV2034427Medicare PIN
WV2034425Medicare PIN
WV2034422Medicare PIN
WV2034426Medicare PIN
WV2034424Medicare PIN