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Organization

FITNESS CLINIC WELLNESS

Active
Organization subpart
No

Provider details

NPI number
Authorized official
MS. BARBARA BROADWATER (EXECUTIVE DIRECTOR)
(601) 983-7494
Entity
Organization

Contact information

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

Taxonomy

Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
225100000X
Physical Therapist
Primary
363LF0000X
Family Nurse Practitioner
871546
MS

Other

Enumeration date
04/26/2016
Last updated
02/09/2017
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