Provider Demographics
NPI:1992395073
Name:LAKE, JENNIFER (MED, LGPC, ADT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MED, LGPC, ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5557 BALTIMORE AVE STE 500-1552
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-1922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5557 BALTIMORE AVE STE 500-1552
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20781-1922
Practice Address - Country:US
Practice Address - Phone:443-201-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X, 101YS0200X
MDLGP10409101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool