Provider Demographics
NPI:1659089373
Name:LIGHTLE, JENNIFER DAWN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:LIGHTLE
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 1:625 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1916
Mailing Address - Country:US
Mailing Address - Phone:304-939-5832
Mailing Address - Fax:
Practice Address - Street 1:625 4TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1916
Practice Address - Country:US
Practice Address - Phone:304-939-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist