Provider Demographics
NPI:1871376657
Name:FERENTZ, JACOB (LGPC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:FERENTZ
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:FERENTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LGPC
Mailing Address - Street 1:10440 SHAKER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2342
Mailing Address - Country:US
Mailing Address - Phone:443-203-8617
Mailing Address - Fax:
Practice Address - Street 1:10440 SHAKER DR STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2342
Practice Address - Country:US
Practice Address - Phone:443-203-8617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11342101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health