Provider Demographics
NPI:1912611245
Name:PHOENIX ASCENSION COUNSELING LLC
Entity Type:Organization
Organization Name:PHOENIX ASCENSION COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUPITER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:847-340-1922
Mailing Address - Street 1:106 E 4TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 E 4TH ST STE A
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2104
Practice Address - Country:US
Practice Address - Phone:847-340-1922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)