MEDICARE: JVM COSMETIC AND WELLNESS SPA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1659733244	OTHER		INDIVIDUAL NPI

General Provider Information

NPI Number	:	1003483355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JVM COSMETIC AND WELLNESS SPA LLC

Provider Business Mailing Address
First Line	:	1501 ALEXANDRIA PIKE STE 114
Second Line	:
City	:	FORT THOMAS
State	:	KY
Zip	:	41075-2561
Country	:	US
Telephone Number	:	513-833-1619
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 ALEXANDRIA PIKE STE 114
Second Line	:
City	:	FORT THOMAS
State	:	KY
Zip	:	41075-2561
Country	:	US
Telephone Number	:	513-833-1619
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MRS. MEGAN KATHLEEN HACKER
Credential	:	NP
Telephone Number	:	513-833-1619

Provider Enumeration Date	:	06/07/2021
Last Update Date	:	10/01/2021

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