=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194353672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMISON BEHAVIORAL WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 03/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 256 HONEYSUCKLE RD STE 12
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36305-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-792-6736
-----------------------------------------------------
Fax | 334-792-6737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 256 HONEYSUCKLE RD STE 12
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36305-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-792-6736
-----------------------------------------------------
Fax | 334-792-6737
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. DALLARIE JAMISON
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 229-309-0684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------