Provider Demographics
NPI:1033772058
Name:DIFFERENT SHADES OF HEALING, LLC
Entity Type:Organization
Organization Name:DIFFERENT SHADES OF HEALING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NASTASSIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-IT
Authorized Official - Phone:414-265-6156
Mailing Address - Street 1:4752 N 78TH CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6830 W VILLARD AVE STE 190
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3968
Practice Address - Country:US
Practice Address - Phone:262-320-7886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071680Medicaid