Provider Demographics
NPI:1073298014
Name:LAZENBY, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LAZENBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 CENTENNIAL WAY
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3714
Mailing Address - Country:US
Mailing Address - Phone:949-250-1101
Mailing Address - Fax:
Practice Address - Street 1:315 CENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3714
Practice Address - Country:US
Practice Address - Phone:949-250-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst