Provider Demographics
NPI:1851712137
Name:LACEWELL, JONATHAN
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:LACEWELL
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 1:800 N MANGUM ST STE 104
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-2260
Mailing Address - Country:US
Mailing Address - Phone:919-450-6446
Mailing Address - Fax:888-227-5443
Practice Address - Street 1:800 N MANGUM ST STE 104
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2260
Practice Address - Country:US
Practice Address - Phone:919-450-6446
Practice Address - Fax:888-227-5443
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health