Healthcare Provider Details

I. General information

NPI: 1124689880
Provider Name (Legal Business Name): EMPOWERED SOL WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 103RD ST STE 7
JACKSONVILLE FL
32210-6786
US

IV. Provider business mailing address

7530 103RD ST STE 7
JACKSONVILLE FL
32210-6786
US

V. Phone/Fax

Practice location:
  • Phone: 904-872-2225
  • Fax: 406-559-3241
Mailing address:
  • Phone: 904-872-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRI HUSTON
Title or Position: OWNER
Credential:
Phone: 406-781-2314