Provider Demographics
NPI:1598526907
Name:RENZ, JILLIAN LACY
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LACY
Last Name:RENZ
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 1:2704 BRUCE TER
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1817
Mailing Address - Country:US
Mailing Address - Phone:954-815-6480
Mailing Address - Fax:
Practice Address - Street 1:2704 BRUCE TER
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1817
Practice Address - Country:US
Practice Address - Phone:954-815-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health