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General NPI Number Information
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NPI Number | 1932649662
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Entity Type | Organization
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Legal Business Name | INNER SELF AND WISDOM, LLC
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Dates
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Enumeration Date | 02/28/2017
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Last Update Date | 02/28/2017
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Provider Practice Location Address
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Address Line | 12101 E 2ND AVE
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City | AURORA
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State | CO
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Zip | 80011-8327
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Country | US
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Telephone | 720-975-4368
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Fax |
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Provider Business Mailing Address
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Address Line | 15703 E CASPIAN CIR APT 201
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City | AURORA
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State | CO
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Zip | 80013-6314
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Country | US
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Telephone | 720-975-4368
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Fax |
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Authorized Official
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Title or Position | CEO AND FOUNDER
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Name | MR. JASON SHANKLE
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Credential | MA, LPCC, LACC, CMIT
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Telephone | 720-975-4368
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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 | LPCC.0013487
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | NLC.0107047
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License Number State | CO
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