Contact UsReach out to discuss how we can support your health and wellness journey Have Questions? Let's Talk!If you have questions about our services, programs, or anything else, feel free to reach out. We're here to help!*We typically respond within 24-48 hours* Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLast Do Address describes Email *What service(s) are you interested in? *Accelerated Resolution TherapyBloodwork/Lab Testing (Hormone level, nutritional deficiencies, cholesterol, pregnancy testing, etc.)Contraception/Family PlanningGynecology ExamIV Therapy/Vitamin InjectionsMedical Weight LossPsychiatric MedicationSTD/HIV TestingWhat best describes your financial situation? *I have insurance and I only want services my insurance will cover?I don't have insurance and can pay for services out-of-pocketI have insurance and can also pay for services not covered by insuranceDo you have health insurance? *YesNoInsurance Name *Claim Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMember ID#/Group ID# *Upload Front and Back of Insurance Card Click or drag files to this area to upload. You can upload up to 4 files. Insurance Guarantor? *SelfOtherGuarantor's Name *FirstLastGuarantor's Date of Birth *Guarantor's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSubmit More Ways Phone :402-884-9059 Fax :833-875-0053 Email: info@j2wllc.org Address: 401 E Gold Coast Rd #340, Papillon, NE 68046 Follow Me On Social Media
