Provider Demographics
NPI:1548614472
Name:LANE, JENNIFER (LISW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1617
Mailing Address - Country:US
Mailing Address - Phone:330-480-2616
Mailing Address - Fax:330-480-7979
Practice Address - Street 1:1001 COVINGTON ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1617
Practice Address - Country:US
Practice Address - Phone:330-480-2616
Practice Address - Fax:330-480-7979
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.16001551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211871Medicaid