Provider Demographics
NPI:1457867046
Name:LANE, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 POWDERHORN RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3399
Mailing Address - Country:US
Mailing Address - Phone:864-963-3421
Mailing Address - Fax:864-962-0758
Practice Address - Street 1:20 POWDERHORN RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3399
Practice Address - Country:US
Practice Address - Phone:864-963-3421
Practice Address - Fax:864-962-0758
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health