Provider Demographics
NPI:1538600861
Name:LUTES, JADE (CDCT)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:LUTES
Suffix:
Gender:F
Credentials:CDCT
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:NICOLE
Other - Last Name:LUTES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CDCT
Mailing Address - Street 1:3449 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6952
Mailing Address - Country:US
Mailing Address - Phone:907-486-9800
Mailing Address - Fax:
Practice Address - Street 1:3449 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6952
Practice Address - Country:US
Practice Address - Phone:907-486-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4353101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)