Provider Demographics
NPI:1760107544
Name:HAYNES, JESSICA CHRISTINA (PRSS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHRISTINA
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:CHRISTINA
Other - Last Name:ANGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PRSS
Mailing Address - Street 1:203 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1533
Mailing Address - Country:US
Mailing Address - Phone:304-531-9678
Mailing Address - Fax:
Practice Address - Street 1:908 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1143
Practice Address - Country:US
Practice Address - Phone:304-531-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21-9104175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist