=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689157612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FITNESS N MIND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2018
-----------------------------------------------------
Last Update Date | 11/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 COUNTRYSIDE LN
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53045-5458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-473-2228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 COUNTRYSIDE LN
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53045-5458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-473-2228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JENNIFER LYNE SWANSON
-----------------------------------------------------
Credential | ED.D.
-----------------------------------------------------
Telephone | 206-473-2228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------