Provider Demographics
NPI:1609511369
Name:MINDFUL WELLNESS OF AZ LLC
Entity Type:Organization
Organization Name:MINDFUL WELLNESS OF AZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WELLENGTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-421-6661
Mailing Address - Street 1:8751 N 51ST AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4943
Mailing Address - Country:US
Mailing Address - Phone:520-329-5283
Mailing Address - Fax:
Practice Address - Street 1:8751 N 51ST AVE STE 108
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4943
Practice Address - Country:US
Practice Address - Phone:520-329-5283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ874442042Medicaid