Provider Demographics
NPI:1144876970
Name:LORIMER, JACK WILLIAM
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:WILLIAM
Last Name:LORIMER
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 1:7650 RATTALEE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-1838
Mailing Address - Country:US
Mailing Address - Phone:248-933-7110
Mailing Address - Fax:
Practice Address - Street 1:7650 RATTALEE LAKE RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-1838
Practice Address - Country:US
Practice Address - Phone:248-933-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician