Healthcare Provider Details

I. General information

NPI: 1629482021
Provider Name (Legal Business Name): SOURCE HEALING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N DEARBORN ST STE 800
CHICAGO IL
60654-3874
US

IV. Provider business mailing address

650 N DEARBORN ST STE 800
CHICAGO IL
60654-3874
US

V. Phone/Fax

Practice location:
  • Phone: 312-335-9330
  • Fax:
Mailing address:
  • Phone: 312-335-9330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198-000696
License Number StateIL

VIII. Authorized Official

Name: CHRISTIE JORDAN
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 312-335-9330