MEDICARE: BODY MIND SOUL 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	1041C0700X	Clinical Social Worker	1538351150	MI

General Provider Information

NPI Number	:	1588072763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY MIND SOUL LLC

Provider Business Mailing Address
First Line	:	P.O. BOX 20056
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49019
Country	:	US
Telephone Number	:	269-615-8639
Fax Number	:

Provider Business Practice Location Address
First Line	:	5985 WEST MAIN STREET
Second Line	:	814
City	:	KALAMAZOO
State	:	MI
Zip	:	49009
Country	:	US
Telephone Number	:	269-615-8639
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	PATRICIA A JORGENSON
Credential	:	LMSW
Telephone Number	:	269-615-8639

Provider Enumeration Date	:	07/31/2014
Last Update Date	:	07/31/2014

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