=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235937848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OTR WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2025
-----------------------------------------------------
Last Update Date | 03/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 COLUMBIA RD NW STE 102
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-506-3240
-----------------------------------------------------
Fax | 202-506-1601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 COLUMBIA RD NW STE 102
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-506-3240
-----------------------------------------------------
Fax | 202-506-1601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-PRESIDENT AND TREASURER
-----------------------------------------------------
Name | JENNIFER JILL FUENTES
-----------------------------------------------------
Credential | LPC CAGCS CCTP
-----------------------------------------------------
Telephone | 202-506-3240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------