1710584917 NPI number — JESSICA LEE LANE MS-MFT, ALMFT

Table of content: JESSICA LEE LANE MS-MFT, ALMFT (NPI 1710584917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710584917 NPI number — JESSICA LEE LANE MS-MFT, ALMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANE
Provider First Name:
JESSICA
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS-MFT, ALMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710584917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8616 SCOTT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACHESNEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61115-2586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-914-0063
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5290 WILLIAMS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSCOE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61073-9222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-324-0324
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  208.00854 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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