Healthcare Provider Details

I. General information

NPI: 1710897905
Provider Name (Legal Business Name): JAZMIN LARA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 N CLYBOURN AVE STE 300
CHICAGO IL
60614-7395
US

IV. Provider business mailing address

3405 W 59TH PL
CHICAGO IL
60629-3624
US

V. Phone/Fax

Practice location:
  • Phone: 773-697-8839
  • Fax:
Mailing address:
  • Phone: 773-799-0244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.023389
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: