Provider Demographics
NPI:1407567936
Name:BACK, JAMIE LEE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:BACK
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 1:285 STOVER FRK
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-8625
Mailing Address - Country:US
Mailing Address - Phone:304-373-8977
Mailing Address - Fax:
Practice Address - Street 1:285 STOVER FRK
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-8625
Practice Address - Country:US
Practice Address - Phone:304-373-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant