Provider Demographics
NPI:1497552566
Name:LANE, JACQUELINE CAROL
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CAROL
Last Name:LANE
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 1:525 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1185
Mailing Address - Country:US
Mailing Address - Phone:815-322-7254
Mailing Address - Fax:
Practice Address - Street 1:525 E NORTH ST
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1185
Practice Address - Country:US
Practice Address - Phone:815-322-7254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical