Healthcare Provider Details

I. General information

NPI: 1881280105
Provider Name (Legal Business Name): KENYA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 LAKE ST STE 720&800
OAK PARK IL
60301-1422
US

IV. Provider business mailing address

715 LAKE ST
OAK PARK IL
60301-1422
US

V. Phone/Fax

Practice location:
  • Phone: 773-312-3612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.018938
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: