Provider Demographics
NPI:1366445843
Name:LAW, JODI L (CFNP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:LAW
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 GRAND CENTRAL AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1082
Mailing Address - Country:US
Mailing Address - Phone:304-422-5600
Mailing Address - Fax:304-422-5993
Practice Address - Street 1:1601 GRAND CENTRAL AVE STE 5
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1082
Practice Address - Country:US
Practice Address - Phone:304-422-5600
Practice Address - Fax:304-422-5993
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV63591363LF0000X, 363LF0000X
WVAPRN3591-FNP-BC207Q00000X
WVAPRN363591-FNP-BC207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1366445843Medicaid