Healthcare Provider Details

I. General information

NPI: 1194554410
Provider Name (Legal Business Name): JRW WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 W LA ENTRADA
CORRALES NM
87048-8605
US

IV. Provider business mailing address

PO BOX 6
CORRALES NM
87048-0006
US

V. Phone/Fax

Practice location:
  • Phone: 619-252-6187
  • Fax:
Mailing address:
  • Phone: 619-252-6187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALLISON WEST
Title or Position: NURSE PRACTITIONER
Credential: FNP, PMHNP
Phone: 619-252-6187