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General NPI Number Information
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NPI Number | 1528703014
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Entity Type | Organization
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Legal Business Name | TRANSFORMATIVE WELLNESS, INC
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Dates
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Enumeration Date | 04/29/2022
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Last Update Date | 05/25/2022
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Provider Practice Location Address
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Address Line | 611 W BRIAR PL STE 6
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City | CHICAGO
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State | IL
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Zip | 60657-4560
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Country | US
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Telephone | 312-375-5621
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Fax |
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Provider Business Mailing Address
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Address Line | 7725 S CRANDON AVE
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City | CHICAGO
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State | IL
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Zip | 60649-4118
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Country | US
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Telephone | 312-375-5621
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CLINICAL PSYCHOLOGIST
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Name | DR. MAUDETTE M JACKSON
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Credential | PHD
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Telephone | 312-375-5621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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