Provider Demographics
NPI:1245602358
Name:LENTZ, JACQUELINE (LCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LENTZ
Suffix:
Gender:F
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-4350
Practice Address - Country:US
Practice Address - Phone:765-298-4600
Practice Address - Fax:765-298-4990
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001464A101YA0400X
IN34007221A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN165490161Medicare PIN