Provider Demographics
NPI:1619641560
Name:AMY M. JAKUBIAK, LCSW, LLC
Entity Type:Organization
Organization Name:AMY M. JAKUBIAK, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JAKUBIAK
Authorized Official - Suffix:
Authorized Official - Credentials:LLC, LCSW
Authorized Official - Phone:773-507-3631
Mailing Address - Street 1:72 S LA GRANGE RD STE 12
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6317
Mailing Address - Country:US
Mailing Address - Phone:773-507-3631
Mailing Address - Fax:
Practice Address - Street 1:72 S LA GRANGE RD STE 12
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6317
Practice Address - Country:US
Practice Address - Phone:773-507-3631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty