Provider Demographics
NPI:1710599006
Name:BROWN, JACQUELINE WICKLINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:WICKLINE
Last Name:BROWN
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 1:519 FORT SPRING PIKE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8093
Mailing Address - Country:US
Mailing Address - Phone:304-661-2158
Mailing Address - Fax:
Practice Address - Street 1:519 FORT SPRING PIKE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8093
Practice Address - Country:US
Practice Address - Phone:304-661-2158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant