Provider Demographics
NPI:1053412510
Name:JARRELL, TERESA E (MA)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:E
Last Name:JARRELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BLAND ST
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3747
Mailing Address - Country:US
Mailing Address - Phone:304-323-1627
Mailing Address - Fax:304-323-1627
Practice Address - Street 1:1500 BLAND ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3747
Practice Address - Country:US
Practice Address - Phone:304-323-1627
Practice Address - Fax:304-323-1627
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV846103T00000X
VA0803000189103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9202138000Medicaid