Provider Demographics
NPI:1073255055
Name:MIND, BODY & SOUL BEHAVIORAL HEALTH PLLC
Entity Type:Organization
Organization Name:MIND, BODY & SOUL BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMH-NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:INEZ
Authorized Official - Last Name:MCLEAN-RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN/NP
Authorized Official - Phone:919-638-4115
Mailing Address - Street 1:505 GRAMMERCY PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2887
Mailing Address - Country:US
Mailing Address - Phone:919-908-8370
Mailing Address - Fax:984-278-6614
Practice Address - Street 1:505 GRAMMERCY PL
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2887
Practice Address - Country:US
Practice Address - Phone:919-908-8370
Practice Address - Fax:984-278-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty