Provider Demographics
NPI:1396896080
Name:TAYLOR, JENNIFER ANNE (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1 MEDICAL PARK
Mailing Address - Street 2:SUITE 704
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-243-3134
Mailing Address - Fax:304-243-3824
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:SUITE 704
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-3134
Practice Address - Fax:304-243-3824
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000749363AS0400X, 363A00000X
WV00398363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119655Medicaid
OHPA22873Medicare ID - Type Unspecified
OHPA22872Medicare ID - Type Unspecified
WVPA22871Medicare ID - Type Unspecified