1801199302 NPI number — JENNIFER MARIE LAKE M.A., LMFT

Table of content: JENNIFER MARIE LAKE M.A., LMFT (NPI 1801199302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801199302 NPI number — JENNIFER MARIE LAKE M.A., LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAKE
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KETZ
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, LMFT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801199302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8119 50TH AVE. N.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HOPE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-799-8258
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2233 N. HAMLINE AVE., SUITE 411
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-799-8258
Provider Business Practice Location Address Fax Number:
651-330-8718
Provider Enumeration Date:
12/06/2010

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 2425 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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