Provider Demographics
NPI:1598534711
Name:GENESIS INTEGRATIVE MENTAL HEALTH
Entity Type:Organization
Organization Name:GENESIS INTEGRATIVE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/EMPLOYEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:302-232-6172
Mailing Address - Street 1:8 THE GRN STE A
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3618
Mailing Address - Country:US
Mailing Address - Phone:302-232-6172
Mailing Address - Fax:628-300-2429
Practice Address - Street 1:8 THE GRN STE A
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3618
Practice Address - Country:US
Practice Address - Phone:302-232-6172
Practice Address - Fax:628-300-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty