Healthcare Provider Details

I. General information

NPI: 1609511369
Provider Name (Legal Business Name): MINDFUL WELLNESS OF AZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8751 N 51ST AVE STE 108
GLENDALE AZ
85302-4943
US

IV. Provider business mailing address

8751 N 51ST AVE STE 108
GLENDALE AZ
85302-4943
US

V. Phone/Fax

Practice location:
  • Phone: 520-329-5283
  • Fax:
Mailing address:
  • Phone: 520-329-5283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WELLENGTEN JENKINS
Title or Position: MANAGING PARTNER
Credential:
Phone: 602-421-6661