=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003067307
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA JACKMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2008
-----------------------------------------------------
Last Update Date | 10/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 MAPLE RD
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60432-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-735-0732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 604 LAMBETH LN
-----------------------------------------------------
City | NEW LENOX
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60451-9638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 180.003361
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------