Provider Demographics
NPI:1821723982
Name:LUTZ, JENNIFER (RBT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 FAIRPOINT DR STE G
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4380
Mailing Address - Country:US
Mailing Address - Phone:507-339-3368
Mailing Address - Fax:
Practice Address - Street 1:41 FAIRPOINT DR STE G
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4380
Practice Address - Country:US
Practice Address - Phone:507-339-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL320424738300OtherDRIVER'S LICENSE