Provider Demographics
NPI:1679951917
Name:LAKESIDE COMMUNITY COMMITTEE
Entity Type:Organization
Organization Name:LAKESIDE COMMUNITY COMMITTEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-224-9217
Mailing Address - Street 1:7418 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-1912
Mailing Address - Country:US
Mailing Address - Phone:773-224-9217
Mailing Address - Fax:773-224-9468
Practice Address - Street 1:7418 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1912
Practice Address - Country:US
Practice Address - Phone:773-224-9217
Practice Address - Fax:773-224-9468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL15003Medicaid