Provider Demographics
NPI:1760433254
Name:CANTERBURY, JAYNE LADIER (DO)
Entity Type:Individual
Prefix:MRS
First Name:JAYNE
Middle Name:LADIER
Last Name:CANTERBURY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:15 DUNLAP STREET
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983-0646
Mailing Address - Country:US
Mailing Address - Phone:304-772-5555
Mailing Address - Fax:304-772-5553
Practice Address - Street 1:15 DUNLAP STREET
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983-0646
Practice Address - Country:US
Practice Address - Phone:304-772-5555
Practice Address - Fax:304-772-5553
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5004699OtherAETNA
WV00190786OtherBCBS MOUNTAIN STATE
WV172431OtherUMWA
WV1802020000Medicaid
WV00348473OtherRAILROAD MEDICARE
WV5004699OtherAETNA
WV0853442Medicare PIN