1104565605 NPI number — WILLOW GROVE WELLNESS, LLC

Table of content: MAEGAN LANETTE JORDAN PHARM.D. (NPI 1801117908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104565605 NPI number — WILLOW GROVE WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW GROVE WELLNESS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104565605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3129 25TH ST # 224
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47203-2436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-426-1847
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10315 S 275 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAT ROCK
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47234-9730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-426-1847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
V
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
317-426-1847

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1255733689 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1972071405 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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