Provider Demographics
NPI:1477232957
Name:STATEN, JERRICA C (LGSW)
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:C
Last Name:STATEN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1506
Mailing Address - Country:US
Mailing Address - Phone:304-641-7677
Mailing Address - Fax:
Practice Address - Street 1:120 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-4599
Practice Address - Country:US
Practice Address - Phone:304-460-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSW062316664104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker