Healthcare Provider Details

I. General information

NPI: 1073298014
Provider Name (Legal Business Name): JACK LAZENBY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 CENTENNIAL WAY
TUSTIN CA
92780-3714
US

IV. Provider business mailing address

315 CENTENNIAL WAY
TUSTIN CA
92780-3714
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-1101
  • Fax:
Mailing address:
  • Phone: 949-250-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: