Provider Demographics
NPI:1104642487
Name:LAJARA, TIFFANY (WAVER PROVIDER)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LAJARA
Suffix:
Gender:F
Credentials:WAVER PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1224
Mailing Address - Country:US
Mailing Address - Phone:475-999-4284
Mailing Address - Fax:
Practice Address - Street 1:92 LEWIS ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1224
Practice Address - Country:US
Practice Address - Phone:475-999-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT228588899171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator