Basic Information
Provider Information
NPI: 1003143710
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LANTZ
FirstName: JENNIFER
MiddleName: MARJEAN
NamePrefix:  
NameSuffix:  
Credential: MS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 105 PLAYA RIENTA WAY
Address2:  
City: PALM BEACH GARDENS
State: FL
PostalCode: 334186210
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3307 NORTHLAKE BLVD
Address2: STE 104
City: PALM BEACH GARDENS
State: FL
PostalCode: 334031703
CountryCode: US
TelephoneNumber: 5616760928
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/17/2009
LastUpdateDate: 11/17/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  N Behavioral Health & Social Service ProvidersCounselor 
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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