Provider Demographics
NPI:1790173656
Name:JACK, LAUREN (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 R ST
Mailing Address - Street 2:
Mailing Address - City:LAKE LOTAWANA
Mailing Address - State:MO
Mailing Address - Zip Code:64086-9429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 R ST
Practice Address - Street 2:
Practice Address - City:LAKE LOTAWANA
Practice Address - State:MO
Practice Address - Zip Code:64086-9429
Practice Address - Country:US
Practice Address - Phone:816-213-5943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3301235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist