Basic Information
| Provider Information | |||||||||
| NPI: | 1083633937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIFFE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1106 | ||||||||
| Address2: | |||||||||
| City: | FREEMAN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 24724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045896399 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3997 BECKLEY RD | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247407660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044315499 | ||||||||
| FaxNumber: | 3044313400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 686 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | CD7656 | 01 | WV | RR MC | OTHER | 0035334000 | 05 | WV | MEDICAID | 3810000421 | 05 | WV | MEDICAID | 001748653 | 01 | WV | BCBS | OTHER | 0022360001 | 05 | WV | MEDICAID | 001748611 | 01 | WV | BCBS | OTHER |