Provider Demographics
NPI:1356553754
Name:SKIN WELLNESS CENTER OF CHICAGO, SC
Entity type:Organization
Organization Name:SKIN WELLNESS CENTER OF CHICAGO, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-236-9950
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:SUITE # 1116
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-236-9950
Mailing Address - Fax:312-236-9951
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE # 1116
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-236-9950
Practice Address - Fax:312-236-9951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty