Healthcare Provider Details

I. General information

NPI: 1235749359
Provider Name (Legal Business Name): JM WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DONAGHEY AVE
CONWAY AR
72035-5001
US

IV. Provider business mailing address

1060 APPLEWOOD DR
CONWAY AR
72034-3538
US

V. Phone/Fax

Practice location:
  • Phone: 501-733-6575
  • Fax:
Mailing address:
  • Phone: 501-733-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY MAYO
Title or Position: OWNER
Credential: PHD, RD
Phone: 501-733-6575