Healthcare Provider Details

I. General information

NPI: 1548788821
Provider Name (Legal Business Name): ELLYN ELIZABETH JAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 N KENSINGTON AVE
LA GRANGE PARK IL
60526-1870
US

IV. Provider business mailing address

150 W SAINT CHARLES RD APT 604
LOMBARD IL
60148-2280
US

V. Phone/Fax

Practice location:
  • Phone: 312-965-2997
  • Fax:
Mailing address:
  • Phone: 630-956-3827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-39429
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: