Basic Information
| Provider Information | |||||||||
| NPI: | 1356553754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SKIN WELLNESS CENTER OF CHICAGO, SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 N WABASH AVE | ||||||||
| Address2: | SUITE # 1116 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606021903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122369950 | ||||||||
| FaxNumber: | 3122369951 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 N WABASH AVE | ||||||||
| Address2: | SUITE # 1116 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606021903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122369950 | ||||||||
| FaxNumber: | 3122369951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | BROOKE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, OWNER, MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3122369950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.