Provider Demographics
NPI:1558849919
Name:CULTIVATE YOUR ESSENCE
Entity Type:Organization
Organization Name:CULTIVATE YOUR ESSENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CDVP
Authorized Official - Phone:708-238-0445
Mailing Address - Street 1:1046 LIONCREST DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1316
Mailing Address - Country:US
Mailing Address - Phone:708-238-0445
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:708-238-0445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-29
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010875261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)