Provider Demographics
NPI:1679199780
Name:PEDEN, JAMIE LYNN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:PEDEN
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 1:3031 CRESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-1651
Mailing Address - Country:US
Mailing Address - Phone:304-389-1194
Mailing Address - Fax:
Practice Address - Street 1:3031 CRESTWOOD RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-1651
Practice Address - Country:US
Practice Address - Phone:304-389-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39384163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant