Provider Demographics
NPI:1467693242
Name:LANE, JILL DEANNA (MS, MHC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DEANNA
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3404
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:260-481-2709
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN39002627A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health