Provider Demographics
NPI:1336369172
Name:LU, JACK (LCSW, MSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:LU
Suffix:
Gender:M
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WATERBURY RD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1242
Mailing Address - Country:US
Mailing Address - Phone:860-878-5648
Mailing Address - Fax:
Practice Address - Street 1:44 WATERBURY RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1242
Practice Address - Country:US
Practice Address - Phone:860-878-5648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical