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General NPI Number Information
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NPI Number | 1285819342
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Entity Type | Organization
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Legal Business Name | GRANT ADVOCATE & COUNSELING SVC OF IL
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Dates
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Enumeration Date | 01/08/2008
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Last Update Date | 01/08/2008
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Provider Practice Location Address
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Address Line | 1649 E 50TH ST #7E
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City | CHICAGO
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State | IL
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Zip | 60615-3128
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Country | US
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Telephone | 773-629-0524
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 803031
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City | CHICAGO
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State | IL
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Zip | 60680-3031
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Country | US
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Telephone | 773-629-0524
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | DR. JERISA C. JOHNSON
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Credential | D.O.
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Telephone | 773-629-0524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | IL
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