Provider Demographics
NPI:1699318501
Name:LALLY, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:LALLY
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 1:17 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-5448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 MORAN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1832
Practice Address - Country:US
Practice Address - Phone:973-862-6066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional