Provider Demographics
NPI:1023127818
Name:MOMEN, JENNIFER JILL
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JILL
Last Name:MOMEN
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:PO BOX 390
Mailing Address - Street 2:11 CHENOWETH DRIVE
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-842-5777
Mailing Address - Fax:304-842-3318
Practice Address - Street 1:11 CHENOWETH DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:303-842-5777
Practice Address - Fax:304-842-3318
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV18808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0110704000Medicaid