Healthcare Provider Details

I. General information

NPI: 1578110441
Provider Name (Legal Business Name): JACOB LUTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2019
Last Update Date: 08/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

3997 BUFFALO TRCE
MADISONVILLE KY
42431-8671
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1147371
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: