Healthcare Provider Details

I. General information

NPI: 1114842408
Provider Name (Legal Business Name): JASMINE GINGER MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5628 S PRAIRIE AVE
CHICAGO IL
60637-1234
US

IV. Provider business mailing address

5628 S PRAIRIE AVE
CHICAGO IL
60637-1234
US

V. Phone/Fax

Practice location:
  • Phone: 773-491-6476
  • Fax:
Mailing address:
  • Phone: 773-491-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150110182
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150110182
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: