Provider Demographics
NPI:1346490661
Name:LASKO, JACEK (PT)
Entity Type:Individual
Prefix:
First Name:JACEK
Middle Name:
Last Name:LASKO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SENECA TRL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2429
Mailing Address - Country:US
Mailing Address - Phone:630-307-6951
Mailing Address - Fax:
Practice Address - Street 1:154 S BLOOMINGDALE RD
Practice Address - Street 2:STE 103
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1498
Practice Address - Country:US
Practice Address - Phone:630-307-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist