Provider Demographics
NPI:1336726827
Name:SELENE INTEGRATIVE CARE PLLC
Entity Type:Organization
Organization Name:SELENE INTEGRATIVE CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:901-361-6822
Mailing Address - Street 1:555 S B B KING BLVD UNIT 1341
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-1057
Mailing Address - Country:US
Mailing Address - Phone:901-361-6822
Mailing Address - Fax:
Practice Address - Street 1:109 W DEMPSTER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109
Practice Address - Country:US
Practice Address - Phone:901-361-6822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service