Provider Demographics
NPI:1083723613
Name:LORENZ, JACK ELLIS (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ELLIS
Last Name:LORENZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512
Mailing Address - Country:US
Mailing Address - Phone:419-782-2250
Mailing Address - Fax:419-784-2347
Practice Address - Street 1:1770 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512
Practice Address - Country:US
Practice Address - Phone:419-782-2250
Practice Address - Fax:419-784-2347
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH676111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000119614OtherANTHEM
OH0340885Medicaid
000000119614OtherANTHEM
9281331Medicare ID - Type Unspecified