Provider Demographics
NPI:1366184079
Name:LANE, JENNIFER R
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:LANE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:DUPO
Mailing Address - State:IL
Mailing Address - Zip Code:62239-1722
Mailing Address - Country:US
Mailing Address - Phone:314-583-5108
Mailing Address - Fax:
Practice Address - Street 1:26 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:DUPO
Practice Address - State:IL
Practice Address - Zip Code:62239-1722
Practice Address - Country:US
Practice Address - Phone:314-583-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YS0200X
MO2022050174101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool