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General NPI Number Information
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NPI Number | 1356553754
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Entity Type | Organization
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Legal Business Name | SKIN WELLNESS CENTER OF CHICAGO, SC
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Dates
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Enumeration Date | 05/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 111 N WABASH AVE SUITE # 1116
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City | CHICAGO
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State | IL
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Zip | 60602-1903
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Country | US
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Telephone | 312-236-9950
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Fax | 312-236-9951
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Provider Business Mailing Address
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Address Line | 111 N WABASH AVE SUITE # 1116
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City | CHICAGO
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State | IL
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Zip | 60602-1903
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Country | US
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Telephone | 312-236-9950
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Fax | 312-236-9951
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Authorized Official
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Title or Position | PRESIDENT, OWNER, MEDICAL DIRECTOR
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Name | DR. BROOKE A. JACKSON
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Credential | MD
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Telephone | 312-236-9950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State | IL
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