Provider Demographics
NPI:1790383669
Name:LATANSKI, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LATANSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 NOTRE DAME DR
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-8527
Mailing Address - Country:US
Mailing Address - Phone:630-561-2703
Mailing Address - Fax:
Practice Address - Street 1:15575 E 127TH ST
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4433
Practice Address - Country:US
Practice Address - Phone:630-257-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist