Provider Demographics
NPI:1184054520
Name:LANE, JACLYN (LMHCA, SUDP)
Entity type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LMHCA, SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 FRONT ST N
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2914
Mailing Address - Country:US
Mailing Address - Phone:425-392-6367
Mailing Address - Fax:
Practice Address - Street 1:17311 135TH AVE NE STE A800
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-3581
Practice Address - Country:US
Practice Address - Phone:425-409-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60250615101YA0400X
WAMC60894412101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)