Provider Demographics
NPI:1770802431
Name:LAKE, JEREMY WILLIAM
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:WILLIAM
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 1:6484 N. 2300 W.
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721
Mailing Address - Country:US
Mailing Address - Phone:435-867-4876
Mailing Address - Fax:
Practice Address - Street 1:6484 N 2300 W
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-7102
Practice Address - Country:US
Practice Address - Phone:435-867-4876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor