Provider Demographics
NPI:1831236900
Name:COULTER, JESSE C (MSW)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:C
Last Name:COULTER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 4 BOX 153
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-9325
Mailing Address - Country:US
Mailing Address - Phone:304-549-3891
Mailing Address - Fax:
Practice Address - Street 1:VET CENTER 521 CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302
Practice Address - Country:US
Practice Address - Phone:304-343-3825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010813151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical