Healthcare Provider Details

I. General information

NPI: 1598282592
Provider Name (Legal Business Name): JACOB MICHAEL LAZAROV LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E MICHIGAN ST
MT PLEASANT MI
48858-2641
US

IV. Provider business mailing address

1840 OAKLAND DR
MT PLEASANT MI
48858-1260
US

V. Phone/Fax

Practice location:
  • Phone: 989-854-1213
  • Fax:
Mailing address:
  • Phone: 989-854-1213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014715
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: