Provider Demographics
NPI:1578110441
Name:LUTZ, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3997 BUFFALO TRCE
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-8671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-202-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1147371163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine