MEDICARE: JEREMY JAMES LANNING LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	70024	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70024	OTHER	TX	STATE OF TEXAS

General Provider Information

NPI Number	:	1255809406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY JAMES LANNING LPC

Provider Business Mailing Address
First Line	:	3309 WINTHROP AVE STE 99
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5600
Country	:	US
Telephone Number	:	817-703-7469
Fax Number	:

Provider Business Practice Location Address
First Line	:	3309 WINTHROP AVE STE 99
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5600
Country	:	US
Telephone Number	:	817-703-7469
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2018
Last Update Date	:	06/11/2019

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