Provider Demographics
NPI:1780062638
Name:MACK, LAURIN JARROLD (PHD)
Entity type:Individual
Prefix:
First Name:LAURIN
Middle Name:JARROLD
Last Name:MACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S PAULINA ST
Mailing Address - Street 2:SUITE 316A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3808
Mailing Address - Country:US
Mailing Address - Phone:312-563-2781
Mailing Address - Fax:
Practice Address - Street 1:710 S PAULINA ST
Practice Address - Street 2:SUITE 316A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3808
Practice Address - Country:US
Practice Address - Phone:312-563-2781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009099103T00000X, 103TC0700X
IL103TH0004X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation