Provider Demographics
NPI:1013920347
Name:SIMON, JENNIFER C (CFNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:SIMON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 99C
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-9703
Mailing Address - Country:US
Mailing Address - Phone:304-372-2731
Mailing Address - Fax:304-372-2749
Practice Address - Street 1:122 PINNELL STREET
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271
Practice Address - Country:US
Practice Address - Phone:304-372-2731
Practice Address - Fax:304-372-2749
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV58536363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006265Medicaid
WV9328803OtherGROUP PTAN
WVWV0245AOtherPTAN
WVWV0245AOtherPTAN
WV3810006265Medicaid
WV9328803OtherGROUP PTAN