Provider Demographics
NPI:1114575669
Name:GROWING BOUNDLESSLY LLC
Entity Type:Organization
Organization Name:GROWING BOUNDLESSLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC
Authorized Official - Prefix:
Authorized Official - First Name:AMARI
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-527-1548
Mailing Address - Street 1:1136 S DELANO CT W STE B201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3734
Practice Address - Country:US
Practice Address - Phone:113-577-7285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty