Provider Demographics
NPI:1548823628
Name:BAIN, JENNA M (CRNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:BAIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1326
Mailing Address - Country:US
Mailing Address - Phone:304-647-6006
Mailing Address - Fax:
Practice Address - Street 1:1320 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:304-647-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV105700363LF0000X
KY4019424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103681661Medicaid