Provider Demographics
NPI:1467413476
Name:COLE, JACQUELINE N (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:N
Last Name:COLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:STE 1500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1100
Mailing Address - Fax:304-691-1153
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:STE 1500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1100
Practice Address - Fax:304-691-1153
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1807624000Medicaid
KY64039076Medicaid
OH2269914Medicaid
KY64039076Medicaid
WVH47501Medicare UPIN