Healthcare Provider Details

I. General information

NPI: 1205759214
Provider Name (Legal Business Name): INNER PEACE HOLISTIC COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8044 S RACINE AVE
CHICAGO IL
60620-3011
US

IV. Provider business mailing address

1139 LEAVITT AVE APT 211
FLOSSMOOR IL
60422-1526
US

V. Phone/Fax

Practice location:
  • Phone: 708-289-0203
  • Fax:
Mailing address:
  • Phone: 708-289-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: KURT JACKSON
Title or Position: OWNER
Credential:
Phone: 708-289-0203