Healthcare Provider Details

I. General information

NPI: 1740265008
Provider Name (Legal Business Name): JEAN LAWRENCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BELVIDERE RD
WAUKEGAN IL
60085-6165
US

IV. Provider business mailing address

PO BOX 178
WADSWORTH IL
60083-0178
US

V. Phone/Fax

Practice location:
  • Phone: 847-377-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: