Healthcare Provider Details

I. General information

NPI: 1326860925
Provider Name (Legal Business Name): MIND OVER MATTER HEALTHCARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 WOODLAND SQUARE LOOP SE # B8
LACEY WA
98503-1000
US

IV. Provider business mailing address

677 WOODLAND SQUARE LOOP SE # B8
LACEY WA
98503-1000
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-4181
  • Fax: 360-539-0972
Mailing address:
  • Phone: 360-623-4181
  • Fax: 360-539-0972

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: DR. JASON RUSSELL JOHNSON
Title or Position: PROVIDER
Credential: DNP, PMHNP-BC
Phone: 360-623-4181