Provider Demographics
NPI:1154320042
Name:JACKER, LAUREN K
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:K
Last Name:JACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1893 SHERIDAN RD
Mailing Address - Street 2:#303
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2628
Mailing Address - Country:US
Mailing Address - Phone:847-831-9304
Mailing Address - Fax:847-831-9594
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:#303
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2628
Practice Address - Country:US
Practice Address - Phone:847-831-9304
Practice Address - Fax:847-831-9594
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360656042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601732OtherBLUE CROSS BLUE SHIELD
IL748160Medicare PIN
IL31601732OtherBLUE CROSS BLUE SHIELD
ILD15933Medicare UPIN