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General NPI Number Information
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NPI Number | 1558849919
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Entity Type | Organization
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Legal Business Name | CULTIVATE YOUR ESSENCE
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Dates
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Enumeration Date | 07/29/2018
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Last Update Date | 07/29/2018
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Provider Practice Location Address
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Address Line | 1136 S DELANO CT W STE B201
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City | CHICAGO
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State | IL
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Zip | 60605-3734
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Country | US
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Telephone | 708-238-0445
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Fax |
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Provider Business Mailing Address
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Address Line | 1046 LIONCREST DR
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City | RICHTON PARK
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State | IL
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Zip | 60471-1316
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Country | US
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Telephone | 708-238-0445
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Fax |
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Authorized Official
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Title or Position | OWNER/LEAD THERAPIST
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Name | MS. LAUREN MICHELLE JACKSON
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Credential | LCPC, CDVP
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Telephone | 708-238-0445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 180.010875
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License Number State | IL
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