Provider Demographics
NPI:1871256669
Name:LASLEY, JAWAN
Entity Type:Individual
Prefix:
First Name:JAWAN
Middle Name:
Last Name:LASLEY
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 1:2600 S. MICHIGAN AVENUE
Mailing Address - Street 2:LLD
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616
Mailing Address - Country:US
Mailing Address - Phone:312-479-3038
Mailing Address - Fax:
Practice Address - Street 1:2600 S. MICHIGAN AVE
Practice Address - Street 2:LLD
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:773-354-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2770024220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily