=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740106020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2026
-----------------------------------------------------
Last Update Date | 06/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 MAIN STREET 18TH FLOOR #2054
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 839-207-0558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 MAIN STREET 18TH FLOOR #2054
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 839-207-0558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP-BC
-----------------------------------------------------
Name | JALISSA CHREE KELLY
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 839-207-0558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------