Provider Demographics
NPI:1295336915
Name:JACOB'S WELL HOLISTIC SERVICES, LLC
Entity type:Organization
Organization Name:JACOB'S WELL HOLISTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROOSA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-BC, CHES
Authorized Official - Phone:816-916-5902
Mailing Address - Street 1:2940 BALTIMORE AVE APT 1207
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-3418
Mailing Address - Country:US
Mailing Address - Phone:816-916-5902
Mailing Address - Fax:
Practice Address - Street 1:3200 STRONG AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66106-2116
Practice Address - Country:US
Practice Address - Phone:913-262-0550
Practice Address - Fax:913-831-3048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care