Healthcare Provider Details

I. General information

NPI: 1811098866
Provider Name (Legal Business Name): ENHANCED WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 10/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DRIVE STE M20
JACKSON MS
39216
US

IV. Provider business mailing address

1855 LAKELAND DRIVE STE M20
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-1132
  • Fax: 601-364-1134
Mailing address:
  • Phone: 601-364-1132
  • Fax: 601-364-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHERINE FELICE BLANCO
Title or Position: CLINIC ADMIN
Credential: RHIA
Phone: 601-364-1132