Provider Demographics
NPI:1912523218
Name:LAWRENCE, JONATHAN WESLEY (LLMSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WESLEY
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 BERWICK DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-2173
Mailing Address - Country:US
Mailing Address - Phone:517-881-8082
Mailing Address - Fax:
Practice Address - Street 1:2111 UNIVERSITY PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6907
Practice Address - Country:US
Practice Address - Phone:517-881-8082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011073651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty