Provider Demographics
NPI:1336571884
Name:LANE, JACQUELINE ELIZABETH (MS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:LANE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 KEMPER ST
Mailing Address - Street 2:
Mailing Address - City:TIMMONSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29161-1922
Mailing Address - Country:US
Mailing Address - Phone:843-346-3956
Mailing Address - Fax:843-346-5159
Practice Address - Street 1:304 KEMPER ST
Practice Address - Street 2:
Practice Address - City:TIMMONSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29161-1922
Practice Address - Country:US
Practice Address - Phone:843-346-3956
Practice Address - Fax:843-346-5159
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4616103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool