Healthcare Provider Details

I. General information

NPI: 1184535064
Provider Name (Legal Business Name): HEADWATERS MENTAL HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 S HWY 89 STE 201
JACKSON WY
83001-8508
US

IV. Provider business mailing address

PO BOX 1243
JACKSON WY
83001-1243
US

V. Phone/Fax

Practice location:
  • Phone: 307-264-0628
  • Fax:
Mailing address:
  • Phone: 307-264-0628
  • Fax:

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: EVE GRINNELL BARNETT
Title or Position: OWNER
Credential: PMHNP
Phone: 503-505-1468