Provider Demographics
NPI:1528602257
Name:RENEW LIFE CONCEPTS, LLC
Entity Type:Organization
Organization Name:RENEW LIFE CONCEPTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADRIAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:317-835-3435
Mailing Address - Street 1:5868 E 71ST ST STE E-630
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4075
Mailing Address - Country:US
Mailing Address - Phone:317-835-3435
Mailing Address - Fax:
Practice Address - Street 1:5868 E 71ST ST STE E-630
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4075
Practice Address - Country:US
Practice Address - Phone:317-835-3435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-06
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN8973191013Medicaid