Provider Demographics
NPI:1083321400
Name:HOPE MENTAL WELLNESS
Entity Type:Organization
Organization Name:HOPE MENTAL WELLNESS
Other - Org Name:HOPE MENTAL WELLNESS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SOLE PROPRIETOR/PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:HOPE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, FNP-BC
Authorized Official - Phone:541-236-2086
Mailing Address - Street 1:P.O. BOX 434
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-236-2086
Mailing Address - Fax:541-214-2897
Practice Address - Street 1:632 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1632
Practice Address - Country:US
Practice Address - Phone:541-236-2086
Practice Address - Fax:541-214-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500794087Medicaid