Healthcare Provider Details

I. General information

NPI: 1003693565
Provider Name (Legal Business Name): JANE LAUREN IGNACIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W BRADLEY PL STE 100
CHICAGO IL
60618-4716
US

IV. Provider business mailing address

2500 W BRADLEY PL STE 100
CHICAGO IL
60618-4716
US

V. Phone/Fax

Practice location:
  • Phone: 877-552-6672
  • Fax:
Mailing address:
  • Phone: 877-552-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61456830
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209027977
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: