Provider Demographics
NPI:1669489985
Name:JANTZEN, CATHERINE MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:MARIE
Last Name:JANTZEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1518
Mailing Address - Country:US
Mailing Address - Phone:260-209-1209
Mailing Address - Fax:260-782-3215
Practice Address - Street 1:6334 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1518
Practice Address - Country:US
Practice Address - Phone:260-209-1209
Practice Address - Fax:260-782-3215
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001451A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200912670AMedicaid