Provider Demographics
NPI:1912934688
Name:COCHRAN, JESSICA (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COCHRAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1334
Mailing Address - Country:US
Mailing Address - Phone:304-647-6549
Mailing Address - Fax:
Practice Address - Street 1:202 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1334
Practice Address - Country:US
Practice Address - Phone:304-647-6549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59214367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005380Medicaid
WVC0823690Medicare ID - Type Unspecified