Provider Demographics
NPI:1245308857
Name:LUTZ, JESSICA L (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:LUTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7335 WESTSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-9703
Mailing Address - Country:US
Mailing Address - Phone:517-622-2788
Mailing Address - Fax:
Practice Address - Street 1:7335 WESTSHIRE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-9703
Practice Address - Country:US
Practice Address - Phone:517-622-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49919-021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI49919-021OtherLICENSE
WIBL9158975OtherDEA LICENSE
WI49919-021OtherLICENSE
000039Medicare Oscar/Certification
WIBL9158975OtherDEA LICENSE
WI000061Medicare Oscar/Certification
WII65839Medicare UPIN
P00697638Medicare Oscar/Certification