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General NPI Number Information
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NPI Number | 1376173401
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Entity Type | Organization
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Legal Business Name | MOONBROOK MIND & BODY INTEGRATIVE SERVICES INCORPORATED
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Dates
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Enumeration Date | 01/16/2020
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Last Update Date | 01/20/2026
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Provider Practice Location Address
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Address Line | 421 PECAN ST
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City | TEXARKANA
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State | AR
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Zip | 71854-5333
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Country | US
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Telephone | 870-330-4095
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Fax | 844-706-5741
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Provider Business Mailing Address
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Address Line | 421 PECAN ST
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City | TEXARKANA
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State | AR
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Zip | 71854-5333
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Country | US
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Telephone | 870-330-4095
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Fax | 844-706-5461
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA KENNINGTON
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Credential |
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Telephone | 870-330-4095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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