Provider Demographics
NPI:1285819342
Name:GRANT ADVOCATE & COUNSELING SVC OF IL
Entity Type:Organization
Organization Name:GRANT ADVOCATE & COUNSELING SVC OF IL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-629-0524
Mailing Address - Street 1:PO BOX 803031
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-3031
Mailing Address - Country:US
Mailing Address - Phone:773-629-0524
Mailing Address - Fax:
Practice Address - Street 1:1649 E 50TH ST
Practice Address - Street 2:#7E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-3128
Practice Address - Country:US
Practice Address - Phone:773-629-0524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health