Provider Demographics
NPI:1609843440
Name:JIVIDEN, SHARON LYNNE (MS CCCA)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LYNNE
Last Name:JIVIDEN
Suffix:
Gender:F
Credentials:MS CCCA
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:LYNNE
Other - Last Name:HEFFINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCCA
Mailing Address - Street 1:508 NEW HOPE ROAD
Mailing Address - Street 2:SUITE #19
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2272
Mailing Address - Country:US
Mailing Address - Phone:304-487-2487
Mailing Address - Fax:304-431-3367
Practice Address - Street 1:508 NEW HOPE ROAD
Practice Address - Street 2:SUITE #19
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2272
Practice Address - Country:US
Practice Address - Phone:304-487-2487
Practice Address - Fax:304-431-3367
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000469231H00000X
VA2101000721231H00000X
WVA0203231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001841Medicaid
0602472OtherPALMETTO GBA MEDICARE PTAN NUMBER PCTN OFFICE
0602473OtherPALMETTO GBA MEDICARE PTAN NUMBER BLFD OFFICE
0602472OtherPALMETTO GBA MEDICARE PTAN NUMBER PCTN OFFICE
0602473OtherPALMETTO GBA MEDICARE PTAN NUMBER BLFD OFFICE