Provider Demographics
NPI:1538406871
Name:RODERICK, JACOB ALLEN (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALLEN
Last Name:RODERICK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CHESS RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:15478-1418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:706-650-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV72425367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9333201OtherMEDICARE GROUP
WV3810025258Medicaid
WV270052997OtherMEDICAID GROUP
WV9333201OtherMEDICARE GROUP