Provider Demographics
NPI:1255809406
Name:LANNING, JEREMY JAMES (LPC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
Last Name:LANNING
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 WINTHROP AVE STE 99
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5600
Mailing Address - Country:US
Mailing Address - Phone:817-703-7469
Mailing Address - Fax:
Practice Address - Street 1:3309 WINTHROP AVE STE 99
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5600
Practice Address - Country:US
Practice Address - Phone:817-703-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX70024OtherSTATE OF TEXAS