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General NPI Number Information
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NPI Number | 1205600103
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Entity Type | Organization
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Legal Business Name | AUTHENTIC CONNECTION SERVICES PLLC
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Dates
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Enumeration Date | 11/10/2023
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Last Update Date | 11/10/2023
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Provider Practice Location Address
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Address Line | 1643 W FARRAGUT AVE APT 1
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City | CHICAGO
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State | IL
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Zip | 60640-0881
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Country | US
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Telephone | 314-757-7241
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Fax |
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Provider Business Mailing Address
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Address Line | 1643 W FARRAGUT AVE APT 1
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City | CHICAGO
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State | IL
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Zip | 60640-0881
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Country | US
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Telephone | 314-757-7241
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | TIMOTHY JOSEPH JORDAN
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Credential | LCPC
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Telephone | 314-757-7241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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