Provider Demographics
NPI:1699197103
Name:JADE MOUNTAIN WELLNESS, INC.
Entity Type:Organization
Organization Name:JADE MOUNTAIN WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:L AC,
Authorized Official - Phone:802-399-2102
Mailing Address - Street 1:1 MILL ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1530
Mailing Address - Country:US
Mailing Address - Phone:802-399-2102
Mailing Address - Fax:
Practice Address - Street 1:1 MILL ST
Practice Address - Street 2:SUITE 305
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1530
Practice Address - Country:US
Practice Address - Phone:802-399-2102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0910000151171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty