Provider Demographics
NPI:1790384477
Name:JAMIE LYNN PEDEN, LLC
Entity Type:Organization
Organization Name:JAMIE LYNN PEDEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-389-1194
Mailing Address - Street 1:3031 CRESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-1651
Mailing Address - Country:US
Mailing Address - Phone:304-389-1194
Mailing Address - Fax:
Practice Address - Street 1:209 WASHINGTON ST W STE 200
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2348
Practice Address - Country:US
Practice Address - Phone:304-314-4052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare