NPIMap

Organization Active NPI

Mandala Counseling & Psychological Services, PLLC

  • Psychologist
  • Chicago, IL
National Provider Identifier
1538724364
Registry record updated May 7, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
Legal business name
MANDALA COUNSELING & PSYCHOLOGICAL SERVICES, PLLC
Practice address
5212 N. Clark Street
Suite 222
Chicago, IL 60640-1223
Phone
(773) 454-7202
Fax
(773) 465-5041
NPI assigned
May 7, 2019
Last updated
May 7, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 7, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kenneth Jackson, PH.D.NPI 1588762108
Title
Owner
Phone
(773) 454-7202

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101Y00000X
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X Primary

Addresses

Primary practice location

5212 N. Clark Street
Suite 222
Chicago, IL 60640-1223

Mailing address

5212 N. Clark Street
Suite 222
Chicago, IL 60640-1223
Phone (773) 454-7202

National Provider Directory

National Provider Directory

Locations

5212 N Clark St
Ste 222
Chicago, IL 60640
Phone (773) 454-7202

5412 N Clark St
#222
Chicago, IL 60640
Phone (773) 454-7202

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1557187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1557187200000",
    "number": "1538724364",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5212 N. CLARK STREET",
            "address_2": "SUITE 222",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606401223",
            "telephone_number": "773-454-7202",
            "fax_number": "773-465-5041"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5212 N. CLARK STREET",
            "address_2": "SUITE 222",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606401223",
            "telephone_number": "773-454-7202",
            "fax_number": "773-465-5041"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MANDALA COUNSELING & PSYCHOLOGICAL SERVICES, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-07",
        "last_updated": "2019-05-07",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "773-454-7202",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 7, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.