Healthcare Provider Details

I. General information

NPI: 1558225656
Provider Name (Legal Business Name): MAHOGANY JAYS WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 MOULIN RD.
DAVENPORT FL
33837
US

IV. Provider business mailing address

7830 LAKE WILSON RD # 1034
DAVENPORT FL
33896-9605
US

V. Phone/Fax

Practice location:
  • Phone: 443-421-0244
  • Fax: 443-421-0244
Mailing address:
  • Phone: 443-421-0244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENITRA B BOST
Title or Position: OWNER
Credential: APRN, FNP, PMHNP
Phone: 443-421-0244