Healthcare Provider Details

I. General information

NPI: 1235682485
Provider Name (Legal Business Name): TIFFANY JEANEEN HOLDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2016
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6618 S DREXEL AVE
CHICAGO IL
60637-6171
US

IV. Provider business mailing address

6618 S DREXEL AVE
CHICAGO IL
60637-6171
US

V. Phone/Fax

Practice location:
  • Phone: 224-322-9858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.0164528
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: