Provider Demographics
NPI:1689406563
Name:QUEEN, JACOB S (PRSS)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:S
Last Name:QUEEN
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 GREENBRIER ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-9623
Mailing Address - Country:US
Mailing Address - Phone:304-553-0051
Mailing Address - Fax:
Practice Address - Street 1:2157 GREENBRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-9623
Practice Address - Country:US
Practice Address - Phone:304-553-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24-9103175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist