Provider Demographics
NPI:1992235659
Name:LAVKO, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:LAVKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BRIGHTON PL
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5751
Mailing Address - Country:US
Mailing Address - Phone:708-990-2573
Mailing Address - Fax:
Practice Address - Street 1:3 BRIGHTON PL
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-5751
Practice Address - Country:US
Practice Address - Phone:630-669-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041450611163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health