Provider Demographics
NPI:1114219037
Name:SUPPPORTED INDEPENDENCE
Entity Type:Organization
Organization Name:SUPPPORTED INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-667-7370
Mailing Address - Street 1:30 S WACKER DR
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-7413
Mailing Address - Country:US
Mailing Address - Phone:630-667-7370
Mailing Address - Fax:312-466-5601
Practice Address - Street 1:30 S WACKER DR
Practice Address - Street 2:SUITE 2200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-7413
Practice Address - Country:US
Practice Address - Phone:630-667-7370
Practice Address - Fax:312-466-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health