Healthcare Provider Details

I. General information

NPI: 1760125926
Provider Name (Legal Business Name): ELIZABETH LAUREN JACOBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 MOON LAKE BLVD
HOFFMAN ESTATES IL
60169-1010
US

IV. Provider business mailing address

1023 BRUCE DR
ELGIN IL
60120-6831
US

V. Phone/Fax

Practice location:
  • Phone: 847-755-8090
  • Fax:
Mailing address:
  • Phone: 847-915-8274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.023248
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: