Provider Demographics
NPI:1679832075
Name:COTTRELL, JESSE N (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:N
Last Name:COTTRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:STE 4500
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1400
Mailing Address - Fax:304-691-1453
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:STE 4500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3656
Practice Address - Country:US
Practice Address - Phone:304-691-1400
Practice Address - Fax:304-691-1453
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV28842207VM0101X
MS24283207VX0000X
390200000X
KYTP405207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100598650Medicaid