Provider Demographics
NPI:1689821068
Name:CHILDERS, JENNIFER LYNN (PHYSICIAN ASSITANT -)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSITANT -
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 WHITE WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-6119
Mailing Address - Country:US
Mailing Address - Phone:304-460-5123
Mailing Address - Fax:800-734-8498
Practice Address - Street 1:1100 MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2737
Practice Address - Country:US
Practice Address - Phone:304-460-5123
Practice Address - Fax:800-734-8498
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WV785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant