Provider Demographics
NPI:1770459521
Name:LAKE, JERIN H
Entity type:Individual
Prefix:
First Name:JERIN
Middle Name:H
Last Name:LAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 W 2700 S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8973
Mailing Address - Country:US
Mailing Address - Phone:801-774-7540
Mailing Address - Fax:
Practice Address - Street 1:1013 W 2700 S
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8973
Practice Address - Country:US
Practice Address - Phone:801-774-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14252296-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor