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  5. LAKE MARY PSYCHIATRY AND COUNSELING, LLC

LAKE MARY PSYCHIATRY AND COUNSELING, LLC

Company Details

Entity Name: LAKE MARY PSYCHIATRY AND COUNSELING, LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 09 Aug 2013 (12 years ago)
Last Event: LC AMENDMENT
Event Date Filed: 12 Nov 2013 (11 years ago)
Document Number: L13000113394
FEI/EIN Number 46-3931533
Address: 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL, 32746, US
Mail Address: 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL, 32746, US
ZIP code: 32746
County: Seminole
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1124456587 2013-10-23 2013-10-23 PO BOX 951468, LAKE MARY, FL, 327951468, US 305 WAYMONT CT, STE 111, LAKE MARY, FL, 327463566, US

Contacts
Phone +1 407-324-0405
Fax 4073240075

Authorized person
Name JEFFREY KROTENBERG
Role MANAGING MEMBER
Phone 4073240405

Taxonomy
Taxonomy Code 2084P0800X - Psychiatry Physician
License Number OS4985
State FL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 056251300
State FL
Issuer VALUE OPTIONS
Number 066470

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
JAK RETIREMENT PLAN AND TRUST 2023 463931533 2024-06-10 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2024-06-10
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2022 463931533 2023-05-30 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2023-05-28
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2021 463931533 2022-07-06 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2022-06-27
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2020 463931533 2021-07-22 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2021-07-22
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2019 463931533 2020-07-21 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2020-07-20
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2018 463931533 2019-07-22 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2019-07-21
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2017 463931533 2018-07-16 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2018-07-13
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-07-13
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2016 463931533 2017-06-26 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2017-06-25
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2015 463931533 2016-07-15 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT CT STE 111, LAKE MARY, FL, 327463566

Signature of
Role Plan administrator
Date 2016-07-14
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-07-14
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature
JAK RETIREMENT PLAN AND TRUST 2014 463931533 2015-09-21 LAKE MARY PSYCHIATRY AND COUNSELING, LLC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1994-01-01
Business code 621111
Sponsor’s telephone number 4073240405
Plan sponsor’s address 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL, 32746

Signature of
Role Plan administrator
Date 2015-09-21
Name of individual signing JEFFREY KROTENBERG
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
KROTENBERG LISA Agent 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL, 32746

Manager

Name Role Address
KROTENBERG JEFFREY A Manager 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL, 32746

Events

Event Type Filed Date Value Description
LC AMENDMENT 2013-11-12 No data No data
CHANGE OF PRINCIPAL ADDRESS 2013-11-12 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL 32746 No data
CHANGE OF MAILING ADDRESS 2013-11-12 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL 32746 No data
REGISTERED AGENT ADDRESS CHANGED 2013-11-12 305 WAYMONT COURT, SUITE 111, LAKE MARY, FL 32746 No data

Documents

Name Date
ANNUAL REPORT 2024-02-22
ANNUAL REPORT 2023-02-23
ANNUAL REPORT 2022-03-17
ANNUAL REPORT 2021-01-29
ANNUAL REPORT 2020-01-23
ANNUAL REPORT 2019-03-25
ANNUAL REPORT 2018-03-18
ANNUAL REPORT 2017-01-10
ANNUAL REPORT 2016-03-07
ANNUAL REPORT 2015-01-06

Related by officers

KROTENBERG LISA

J & J FISH RANCH, LLC ONE ORANGE CAT, LLC

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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