Basic Information
| Provider Information | |||||||||
| NPI: | 1578110441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3997 BUFFALO TRCE | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424318671 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 PRUDENTIAL DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042022000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2019 | ||||||||
| LastUpdateDate: | 08/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 1147371 | KY | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.