Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0004X | Health Psychologist | IL | |
N | 103TR0400X | Rehabilitation Psychologist | IL |
NPI | 1780062638 |
---|---|
Provider Name | Laurin Jarrold Mack |
First Address | Chicago, IL 60612-3808 |
Second Address | Chicago, IL 60612-3808 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2015 |
Last Update Date | 12/05/2015 |