Provider Demographics
NPI:1508023060
Name:BASS, JODY LYNN
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:BASS
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 1:105 ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3733
Mailing Address - Country:US
Mailing Address - Phone:304-256-4500
Mailing Address - Fax:
Practice Address - Street 1:105 ADAIR ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3733
Practice Address - Country:US
Practice Address - Phone:304-256-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44106163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009008Medicaid