Provider Demographics
NPI:1629708409
Name:LANE, JAY WESLEY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:WESLEY
Last Name:LANE
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 1:411 BAINBRIDGE ST APT 152
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2388
Mailing Address - Country:US
Mailing Address - Phone:804-489-7327
Mailing Address - Fax:
Practice Address - Street 1:9351 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-5437
Practice Address - Country:US
Practice Address - Phone:804-352-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst