Provider Demographics
NPI:1326684135
Name:HEART AND SOUL WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:HEART AND SOUL WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP FNP
Authorized Official - Phone:503-428-2498
Mailing Address - Street 1:1025 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4001
Mailing Address - Country:US
Mailing Address - Phone:503-689-1381
Mailing Address - Fax:
Practice Address - Street 1:1025 2ND ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4001
Practice Address - Country:US
Practice Address - Phone:503-689-1381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center