=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902448335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JADE HEALTH & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2019
-----------------------------------------------------
Last Update Date | 09/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 BELAIR RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21213-1257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-929-3893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9627 EAVES DR
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR/CEO
-----------------------------------------------------
Name | THERESSA WILLIAMS
-----------------------------------------------------
Credential | CRNP, FNP-BC
-----------------------------------------------------
Telephone | 443-744-6214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------