Provider Demographics
NPI:1407215320
Name:MOUNTAIN LAUREL WELLNESS LLC
Entity Type:Organization
Organization Name:MOUNTAIN LAUREL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, ALPS
Authorized Official - Phone:304-282-7552
Mailing Address - Street 1:235 HIGH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5429
Mailing Address - Country:US
Mailing Address - Phone:304-282-7552
Mailing Address - Fax:
Practice Address - Street 1:235 HIGH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5429
Practice Address - Country:US
Practice Address - Phone:304-282-7552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1978101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty