Provider Demographics
NPI:1164860052
Name:LUTZ, JACOB THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11104 PARKVIEW CIRCLE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1673
Mailing Address - Country:US
Mailing Address - Phone:260-460-3203
Mailing Address - Fax:260-460-3271
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1673
Practice Address - Country:US
Practice Address - Phone:260-460-3203
Practice Address - Fax:260-460-3271
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042679A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist