=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407201338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LAUTH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2016
-----------------------------------------------------
Last Update Date | 10/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1680 SW BAYSHORE BLVD SUITE 231
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34984-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-361-1416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1680 SW BAYSHORE BLVD SUITE 231
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34984-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-361-1416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11940
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------