Provider Demographics
NPI:1629403563
Name:DURHAM, JENNIFER ROSE (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10003 WEBSTER RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN ON GAULEY
Mailing Address - State:WV
Mailing Address - Zip Code:26208-7713
Mailing Address - Country:US
Mailing Address - Phone:304-226-5725
Mailing Address - Fax:304-226-3274
Practice Address - Street 1:10003 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:CAMDEN ON GAULEY
Practice Address - State:WV
Practice Address - Zip Code:26208-7713
Practice Address - Country:US
Practice Address - Phone:304-226-5725
Practice Address - Fax:304-226-3274
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV73253363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV3488AOtherMEDICARE
WV3810026528Medicaid