Provider Demographics
NPI:1053044701
Name:MIND AND SOUL PSYCHIATRY
Entity Type:Organization
Organization Name:MIND AND SOUL PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-MSN
Authorized Official - Phone:720-587-9702
Mailing Address - Street 1:2505 MINER ST # 1926
Mailing Address - Street 2:
Mailing Address - City:IDAHO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80452-5112
Mailing Address - Country:US
Mailing Address - Phone:720-587-9702
Mailing Address - Fax:
Practice Address - Street 1:2505 MINER ST
Practice Address - Street 2:
Practice Address - City:IDAHO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80452-5112
Practice Address - Country:US
Practice Address - Phone:720-587-9702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty