Provider Demographics
NPI:1144076563
Name:SAMPLES, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:COALTON
Mailing Address - State:WV
Mailing Address - Zip Code:26257-6708
Mailing Address - Country:US
Mailing Address - Phone:304-636-9150
Mailing Address - Fax:
Practice Address - Street 1:278 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:COALTON
Practice Address - State:WV
Practice Address - Zip Code:26257-6708
Practice Address - Country:US
Practice Address - Phone:304-636-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist