Provider Demographics
NPI:1861434177
Name:DYNAMICS OF LIFE
Entity type:Organization
Organization Name:DYNAMICS OF LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-596-5405
Mailing Address - Street 1:14618 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14618 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1610
Practice Address - Country:US
Practice Address - Phone:708-596-5405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID
ILPENDINGMedicare ID - Type Unspecified