Provider Demographics
NPI:1003483355
Name:JVM COSMETIC AND WELLNESS SPA LLC
Entity type:Organization
Organization Name:JVM COSMETIC AND WELLNESS SPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:HACKER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:513-833-1619
Mailing Address - Street 1:1501 ALEXANDRIA PIKE STE 114
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-2561
Mailing Address - Country:US
Mailing Address - Phone:513-833-1619
Mailing Address - Fax:
Practice Address - Street 1:1501 ALEXANDRIA PIKE STE 114
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2561
Practice Address - Country:US
Practice Address - Phone:513-833-1619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100402060Medicaid
1659733244OtherINDIVIDUAL NPI