Provider Demographics
NPI:1073580155
Name:LUTZ, JENNIFER E (MPT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:E
Last Name:LUTZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:108 GLOVER DR.
Mailing Address - Street 2:
Mailing Address - City:MT. ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154
Mailing Address - Country:US
Mailing Address - Phone:937-444-2933
Mailing Address - Fax:937-444-2924
Practice Address - Street 1:108 GLOVER DR
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8390
Practice Address - Country:US
Practice Address - Phone:937-444-2933
Practice Address - Fax:937-444-2924
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT08968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000561960OtherANTHEM
OH2699512Medicaid
000000561960OtherANTHEM
OHLU4233021Medicare PIN