Provider Demographics
NPI:1124775598
Name:LAKE, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 COPPER LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MA
Mailing Address - Zip Code:02330-1763
Mailing Address - Country:US
Mailing Address - Phone:781-760-3730
Mailing Address - Fax:
Practice Address - Street 1:900 SHIP POND RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-1849
Practice Address - Country:US
Practice Address - Phone:508-224-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional