Provider Demographics
NPI:1639881642
Name:ILLUMINATED WELLNESS
Entity Type:Organization
Organization Name:ILLUMINATED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZECK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:319-504-5698
Mailing Address - Street 1:512 W MAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2838
Mailing Address - Country:US
Mailing Address - Phone:319-504-5698
Mailing Address - Fax:
Practice Address - Street 1:512 W MAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2838
Practice Address - Country:US
Practice Address - Phone:319-504-5698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty