# FITNESS CLINIC WELLNESS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1912352022
- **Authorized official:** MS. BARBARA BROADWATER (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (601) 983-7494

## Contact information

- **Practice address:** 2219 GREENWAY DR, JACKSON, MS 39204-3202
- **Practice address phone:** (601) 983-7494
- **Mailing address:** 2219 GREENWAY DR, JACKSON, MS 39204-3202
- **Mailing address phone:** (601) 983-7494

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103TC0700X | Clinical Psychologist | — | NULL | — |
| 103TC0700X | Clinical Psychologist | — | — | — |
| 225100000X | Physical Therapist | — | NULL | Yes |
| 225100000X | Physical Therapist | — | — | Yes |
| 363LF0000X | Family Nurse Practitioner | 871546 | MS | — |

## Other

- **Enumeration date:** 04/26/2016
- **Last updated:** 02/09/2017