Provider Demographics
NPI:1003693565
Name:IGNACIO, JANE LAUREN
Entity type:Individual
Prefix:
First Name:JANE LAUREN
Middle Name:
Last Name:IGNACIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W BRADLEY PL STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4716
Mailing Address - Country:US
Mailing Address - Phone:877-552-6672
Mailing Address - Fax:
Practice Address - Street 1:2500 W BRADLEY PL STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4716
Practice Address - Country:US
Practice Address - Phone:877-552-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61456830363LP0808X
IL209027977363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health