MEDICARE: MOONBROOK MIND & BODY INTEGRATIVE SERVICES INCORPORATED

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	101YP2500X	Professional Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1376173401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOONBROOK MIND & BODY INTEGRATIVE SERVICES INCORPORATED

Provider Business Mailing Address
First Line	:	421 PECAN ST
Second Line	:
City	:	TEXARKANA
State	:	AR
Zip	:	71854-5333
Country	:	US
Telephone Number	:	870-330-4095
Fax Number	:	844-706-5461

Provider Business Practice Location Address
First Line	:	421 PECAN ST
Second Line	:
City	:	TEXARKANA
State	:	AR
Zip	:	71854-5333
Country	:	US
Telephone Number	:	870-330-4095
Fax Number	:	844-706-5741

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA KENNINGTON
Credential	:
Telephone Number	:	870-330-4095

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	01/20/2026

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