=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114255817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKENING MINDFUL POSSIBILITIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2009
-----------------------------------------------------
Last Update Date | 11/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 KENSINGTON PL
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38401-8885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-380-0677
-----------------------------------------------------
Fax | 931-380-0677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 KENSINGTON PL
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38401-8885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-380-0677
-----------------------------------------------------
Fax | 931-380-0677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O./ PRACTITIONER
-----------------------------------------------------
Name | JASON MATTHEW TALLMAN
-----------------------------------------------------
Credential | MSN, RN, APN-BC
-----------------------------------------------------
Telephone | 931-380-0677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APN0000014483
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------