Provider Demographics
NPI:1932649662
Name:INNER SELF AND WISDOM, LLC
Entity type:Organization
Organization Name:INNER SELF AND WISDOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC, LACC, CMIT
Authorized Official - Phone:720-975-4368
Mailing Address - Street 1:15703 E CASPIAN CIR APT 201
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-6314
Mailing Address - Country:US
Mailing Address - Phone:720-975-4368
Mailing Address - Fax:
Practice Address - Street 1:12101 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8327
Practice Address - Country:US
Practice Address - Phone:720-975-4368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0013487251S00000X
CONLC.0107047251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health