Provider Demographics
NPI:1891815916
Name:LIGHTHOUSE WELLNESS CENTERS
Entity Type:Organization
Organization Name:LIGHTHOUSE WELLNESS CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:708-275-0934
Mailing Address - Street 1:5320 159TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3329
Mailing Address - Country:US
Mailing Address - Phone:708-275-0934
Mailing Address - Fax:
Practice Address - Street 1:5320 159TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3329
Practice Address - Country:US
Practice Address - Phone:708-275-0934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-00003704101Y00000X
IL101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty