Healthcare Provider Details

I. General information

NPI: 1356256234
Provider Name (Legal Business Name): MIND THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PLASTICS PL STE 245
KALAMAZOO MI
49001-4882
US

IV. Provider business mailing address

10618 S WALDEN PKWY
CHICAGO IL
60643-2661
US

V. Phone/Fax

Practice location:
  • Phone: 616-522-4027
  • Fax: 616-282-1777
Mailing address:
  • Phone: 773-663-7773
  • Fax: 616-282-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: IRIS JACKSON
Title or Position: OWNER/ CLINICAL DIRECTOR
Credential: LPC, NCC
Phone: 616-522-4027