Provider Demographics
NPI:1285212506
Name:EAGLE, JEFFERY
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:EAGLE
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 1:1703 CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-3329
Mailing Address - Country:US
Mailing Address - Phone:681-404-8713
Mailing Address - Fax:
Practice Address - Street 1:1408 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3325
Practice Address - Country:US
Practice Address - Phone:304-636-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant