=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881336089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2022
-----------------------------------------------------
Last Update Date | 04/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 E 10TH ST
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81001-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-940-4758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 E 10TH ST
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81001-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-940-4758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MASSAGE THERAPIST
-----------------------------------------------------
Name | JONATHAN JOSEPH JENSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-940-4758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------