MEDICARE: KETAMINE WELLNESS CENTERS JACKSONVILLE

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	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1063016988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETAMINE WELLNESS CENTERS JACKSONVILLE

Provider Business Mailing Address
First Line	:	113 W HOOVER AVE STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-5214
Country	:	US
Telephone Number	:	855-538-9355
Fax Number	:	844-538-9355

Provider Business Practice Location Address
First Line	:	3753-2 CARDINAL POINT DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-5582
Country	:	US
Telephone Number	:	855-538-9355
Fax Number	:	844-538-9355

Authorized Official
Title or Position	:	EXECUTIVE ASSISTANT
Name	:	MS. ANITA JERGER
Credential	:
Telephone Number	:	855-538-9355

Provider Enumeration Date	:	11/23/2020
Last Update Date	:	11/23/2020

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