Provider Demographics
NPI:1902570591
Name:ILLUMINATE MY LIFE COUNSELING
Entity Type:Organization
Organization Name:ILLUMINATE MY LIFE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMSW
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GENEREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:231-570-0627
Mailing Address - Street 1:2692 S M 37
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-9187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2692 S M 37
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-9187
Practice Address - Country:US
Practice Address - Phone:231-570-0627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty