Provider Demographics
NPI:1700862661
Name:WILES, JENNIFER M (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WILES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1069529OtherWV DWC
WV001718079OtherWV BCBS
WV24793Medicare PIN
WV24792Medicare PIN
WV24791Medicare PIN
WV1069529OtherWV DWC