=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275473662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLE SOUL THERAPY AND EMDR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2026
-----------------------------------------------------
Last Update Date | 03/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1737 BISCAYNE AVE
-----------------------------------------------------
City | SOUTH DAYTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32119-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-310-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1737 BISCAYNE AVE
-----------------------------------------------------
City | SOUTH DAYTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32119-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-310-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATOR
-----------------------------------------------------
Name | MR. JACOB BRYANT
-----------------------------------------------------
Credential | LCSW, MCAP
-----------------------------------------------------
Telephone | 386-310-9662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------