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General NPI Number Information
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NPI Number | 1407215320
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Entity Type | Organization
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Legal Business Name | MOUNTAIN LAUREL WELLNESS LLC
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Dates
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Enumeration Date | 02/19/2016
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Last Update Date | 02/19/2016
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Provider Practice Location Address
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Address Line | 235 HIGH ST SUITE 407
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City | MORGANTOWN
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State | WV
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Zip | 26505-5429
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Country | US
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Telephone | 304-282-7552
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Fax |
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Provider Business Mailing Address
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Address Line | 235 HIGH ST SUITE 407
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City | MORGANTOWN
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State | WV
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Zip | 26505-5429
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Country | US
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Telephone | 304-282-7552
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Fax |
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Authorized Official
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Title or Position | COUNSELOR
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Name | JAMIE ELIZABETH JACOBS
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Credential | LPC, ALPS
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Telephone | 304-282-7552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 1978
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License Number State | WV
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