Healthcare Provider Details

I. General information

NPI: 1679691380
Provider Name (Legal Business Name): JENNIFER LYNN MOTZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N WAYNE ST
ANGOLA IN
46703-1081
US

IV. Provider business mailing address

PO BOX 98 603 N. WAYNE STREET
ANGOLA IN
46703-0098
US

V. Phone/Fax

Practice location:
  • Phone: 260-668-8797
  • Fax: 260-665-1620
Mailing address:
  • Phone: 260-668-8797
  • Fax: 260-665-1620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34005718A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005718A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: