Individual
JODY HANNAH LACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
415 N 9TH ST, STE 4W64, SPRINGFIELD, IL 62702-5303
(217) 545-0003
(217) 545-7615
Mailing address
PO BOX 19676, SPRINGFIELD, IL 62794-9676
(217) 545-0003
(217) 545-7615
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036-122811
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036122811
—
IL
Enumeration date
05/03/2007
Last updated
01/13/2011
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