Provider Demographics
NPI:1619509544
Name:LORENZO, JACOLYN SU
Entity Type:Individual
Prefix:
First Name:JACOLYN
Middle Name:SU
Last Name:LORENZO
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:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-0209
Mailing Address - Country:US
Mailing Address - Phone:573-723-0847
Mailing Address - Fax:573-302-4685
Practice Address - Street 1:210 W SUNSHINE ST # F
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-2655
Practice Address - Country:US
Practice Address - Phone:417-869-4744
Practice Address - Fax:417-869-4747
Is Sole Proprietor?:No
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO060906163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse