Provider Demographics
NPI:1528571676
Name:HAIR HAVEN
Entity Type:Organization
Organization Name:HAIR HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/HAIR LOSS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:COSMETOLOGIST
Authorized Official - Phone:312-286-3736
Mailing Address - Street 1:2600 S MICHIGAN AVE STE 314
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 S MICHIGAN AVE STE 314
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2860
Practice Address - Country:US
Practice Address - Phone:312-528-0448
Practice Address - Fax:312-528-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-12
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011-2546331744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty