MEDICARE: SOUL PURPOSE WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538881255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL PURPOSE WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	1318 STONE ST
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401-4522
Country	:	US
Telephone Number	:	501-213-1330
Fax Number	:	501-421-2135

Provider Business Practice Location Address
First Line	:	1318 STONE ST
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401-4522
Country	:	US
Telephone Number	:	501-213-1330
Fax Number	:	501-421-2135

Authorized Official
Title or Position	:	OWNER AND THERAPIST
Name	:	KATRINA ADAMS
Credential	:	LCSW
Telephone Number	:	501-213-1330

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	03/13/2024

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