Provider Demographics
NPI:1538724364
Name:MANDALA COUNSELING & PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:MANDALA COUNSELING & PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-454-7202
Mailing Address - Street 1:5212 N. CLARK STREET
Mailing Address - Street 2:SUITE 222
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1223
Mailing Address - Country:US
Mailing Address - Phone:773-454-7202
Mailing Address - Fax:773-465-5041
Practice Address - Street 1:5212 N. CLARK STREET
Practice Address - Street 2:SUITE 222
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1223
Practice Address - Country:US
Practice Address - Phone:773-454-7202
Practice Address - Fax:773-465-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty