Healthcare Provider Details

I. General information

NPI: 1740106020
Provider Name (Legal Business Name): MINDFUL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MAIN STREET 18TH FLOOR #2054
COLUMBIA SC
29180
US

IV. Provider business mailing address

1900 MAIN STREET 18TH FLOOR #2054
COLUMBIA SC
29180
US

V. Phone/Fax

Practice location:
  • Phone: 839-207-0558
  • Fax:
Mailing address:
  • Phone: 839-207-0558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JALISSA CHREE KELLY
Title or Position: PMHNP-BC
Credential: APRN
Phone: 839-207-0558