Provider Demographics
NPI:1154695625
Name:LANE, JEREMY DAVID (LPC, NCC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:LANE
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 EAST 3RD ST. (APT. 5)
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161
Mailing Address - Country:US
Mailing Address - Phone:404-425-6264
Mailing Address - Fax:
Practice Address - Street 1:309 E 3RD ST APT 5
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3194
Practice Address - Country:US
Practice Address - Phone:404-425-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006218101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health