Provider Demographics
NPI:1366943987
Name:WHITED, JESSIE FORD
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:FORD
Last Name:WHITED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:MORGAN
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:345 POCAHONTAS TRL
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-9793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 POCAHONTAS TRL
Practice Address - Street 2:
Practice Address - City:WHITE SULPHUR SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986-9793
Practice Address - Country:US
Practice Address - Phone:304-536-4661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002420225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant