Provider Demographics
NPI:1992522965
Name:WISE WILLOW INC
Entity type:Organization
Organization Name:WISE WILLOW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:708-275-0934
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-0764
Mailing Address - Country:US
Mailing Address - Phone:708-275-0934
Mailing Address - Fax:
Practice Address - Street 1:10522 S CICERO AVE STE 304
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5292
Practice Address - Country:US
Practice Address - Phone:708-275-0934
Practice Address - Fax:888-419-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health