Provider Demographics
NPI:1053994996
Name:BROGAN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BROGAN
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:WV
Mailing Address - Zip Code:25878-0190
Mailing Address - Country:US
Mailing Address - Phone:304-207-4829
Mailing Address - Fax:
Practice Address - Street 1:108 VENICE CT
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:WV
Practice Address - Zip Code:25878
Practice Address - Country:US
Practice Address - Phone:304-676-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker