NPIMap

Organization Active NPI

Willow Grove Wellness, LLC

  • Clinical Social Worker
  • Flat Rock, IN
National Provider Identifier
1104565605
Registry record updated Jun 2, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
Legal business name
WILLOW GROVE WELLNESS, LLC
Practice address
10315 S 275 E
Flat Rock, IN 47234-9730
Phone
(317) 426-1847
NPI assigned
Jun 2, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Jessica V Jacobs, LCSWNPI 1255733689
Title
Owner
Phone
(317) 426-1847

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social WorkerGroup: 193400000X SINGLE SPECIALTY GROUP 1041C0700X Primary

Addresses

Primary practice location

10315 S 275 E
Flat Rock, IN 47234-9730

Mailing address

3129 25TH St # 224
Columbus, IN 47203-2436
Phone (317) 426-1847

Other identifiers 2

IdentifierTypeStateIssuer
1255733689MedicaidIN
1972071405MedicaidIN

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL https://secure.simplepractice.com/ Direct

National Provider Directory

National Provider Directory

Locations

3129 25th St
Columbus, IN 47203

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1654128000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654128000000",
    "number": "1104565605",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3129 25TH ST # 224",
            "city": "COLUMBUS",
            "state": "IN",
            "postal_code": "472032436",
            "telephone_number": "317-426-1847"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10315 S 275 E",
            "city": "FLAT ROCK",
            "state": "IN",
            "postal_code": "472349730",
            "telephone_number": "317-426-1847"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILLOW GROVE WELLNESS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-02",
        "last_updated": "2022-06-02",
        "certification_date": "2022-06-02",
        "status": "A",
        "authorized_official_last_name": "JACOBS",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "317-426-1847",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1255733689",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1972071405",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "https://secure.simplepractice.com/",
            "affiliation": "N",
            "endpointDescription": "Simple Practice Electronic Medical Record Messaging System",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "HIPAA Compliant Secure System",
            "address_1": "10315 S 275 E",
            "city": "Flat Rock",
            "state": "IN",
            "country_code": "US",
            "postal_code": "472349730",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Flat Rock, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.