Provider Demographics
NPI:1104565605
Name:WILLOW GROVE WELLNESS, LLC
Entity type:Organization
Organization Name:WILLOW GROVE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-426-1847
Mailing Address - Street 1:3129 25TH ST # 224
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2436
Mailing Address - Country:US
Mailing Address - Phone:317-426-1847
Mailing Address - Fax:
Practice Address - Street 1:10315 S 275 E
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:IN
Practice Address - Zip Code:47234-9730
Practice Address - Country:US
Practice Address - Phone:317-426-1847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1255733689Medicaid
IN1972071405Medicaid