Provider Demographics
NPI:1063016988
Name:KETAMINE WELLNESS CENTERS JACKSONVILLE
Entity Type:Organization
Organization Name:KETAMINE WELLNESS CENTERS JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-538-9355
Mailing Address - Street 1:113 W HOOVER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5214
Mailing Address - Country:US
Mailing Address - Phone:855-538-9355
Mailing Address - Fax:844-538-9355
Practice Address - Street 1:3753-2 CARDINAL POINT DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5582
Practice Address - Country:US
Practice Address - Phone:855-538-9355
Practice Address - Fax:844-538-9355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETAMINE WELLNESS CENTERS ARIZONA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty