Provider Demographics
NPI:1225368368
Name:LENTZ, JACQUELINE (NP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:LENTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-5558
Mailing Address - Country:US
Mailing Address - Phone:970-494-6449
Mailing Address - Fax:970-482-0198
Practice Address - Street 1:1365 W 29TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2561
Practice Address - Country:US
Practice Address - Phone:970-667-6111
Practice Address - Fax:970-482-0198
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2008006015363LA2200X
OR2008006016363LG0600X
OR201050005NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500619570Medicaid
OR500619570Medicaid