Healthcare Provider Details

I. General information

NPI: 1164046447
Provider Name (Legal Business Name): JACOB LORENZ BA, MHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OLIVER ST
VIENNA IL
62995-1660
US

IV. Provider business mailing address

101 OLIVER ST
VIENNA IL
62995-1660
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax: 618-658-2501
Mailing address:
  • Phone: 618-658-2611
  • Fax: 618-658-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: