Healthcare Provider Details

I. General information

NPI: 1235937848
Provider Name (Legal Business Name): OTR WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 COLUMBIA RD NW STE 102
WASHINGTON DC
20009-2031
US

IV. Provider business mailing address

1801 COLUMBIA RD NW STE 102
WASHINGTON DC
20009-2031
US

V. Phone/Fax

Practice location:
  • Phone: 202-506-3240
  • Fax: 202-506-1601
Mailing address:
  • Phone: 202-506-3240
  • Fax: 202-506-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER JILL FUENTES
Title or Position: CO-PRESIDENT AND TREASURER
Credential: LPC CAGCS CCTP
Phone: 202-506-3240