MEDICARE: MIND AND SOUL PSYCHIATRY

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1053044701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND AND SOUL PSYCHIATRY

Provider Business Mailing Address
First Line	:	2505 MINER ST # 1926
Second Line	:
City	:	IDAHO SPRINGS
State	:	CO
Zip	:	80452-5112
Country	:	US
Telephone Number	:	720-587-9702
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 MINER ST
Second Line	:
City	:	IDAHO SPRINGS
State	:	CO
Zip	:	80452-5112
Country	:	US
Telephone Number	:	720-587-9702
Fax Number	:

Authorized Official
Title or Position	:	PMHNP-BC
Name	:	JENNIFER MEDINA
Credential	:	APRN-MSN
Telephone Number	:	720-587-9702

Provider Enumeration Date	:	07/08/2022
Last Update Date	:	07/15/2022

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